Skip to main content

Full text of "A practical treatise on diseases of the skin for the use of students and practitioners"

See other formats


MEDICAL 
LUIB 




Digitized by the Internet Archive 
in 2012 



http://archive.org/details/practicaltreatisOOorms 



PLATE I 




Xeroderma Pigmentosum 

(From a Painting in oil ) 



,\ PRA< Tl< !AL TREATISE 



DISEASES OF THE SKIN 



FOR TIIK (Si; OF 



STUDENTS AM) PRACTITIONERS 



BY 

OLIVER S. QEMSBY, M.D. 

PROFESSOR AND HEAD OF THE DEPARTMENT OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLET, E I N 

AFFILIATION WITH THE UNIVERSITY OF CHICAGO); DERMATOLOGIST TO THE PRESBYTERIAN, CHILDREN'S 

MEMORIAL, SAINT ANTHONY'S, AND WEST SUBURBAN HOSPITALS, THE HOME FOR DESTITUTE 

CRIPPLED CHILDREN, AND THE ORPHAN ASYLUM OF THE CITY OF CHICAGO; MEMBER OF 

THE AMERICAN DERMATOLOGICAL ASSOCIATION AND OF THE CONGR I 

AMERICAN PHYSICIANS AND SURGEONS 



ILLUSTRATED WITH 303 ENGRAVINGS AND 39 PLATES IN 
COLORS AND MONOCHROME 




LEA & FE BIG E R 

PHI LA DELPH I A AN 1) N EW 5 OB K 



Entered *»■ to the Act of Congre* in the year 1*6. by 

I E \ 4 FEBIGER, 
Office of the Libran, ! Congre*. frights. rved. 



PREFACE 



It has been the aim of the author in this volume to present the 

subject of cutaneous diseases in sufficient detail to be of value to 
the student and practitioner of medicine wishing information in this 
department. The work has been made as concise as possible, yet is of 
sufficient scope to cover the field, including the important advances 
made during the past few years. In the preparation of the work the 
author has freely used parts of the treatise of his illustrious colleagues, 
the late Drs. James Nevins Hyde and Frank Hugh Montgomery, for 
all of which he desires to express his deep appreciation. 

Many well-defined new diseases have recently been differentiated, 
and new facts concerning the nature and course of those previously 
recognized have been discovered by investigators in various parts of 
the world. All advances have been duly noted. Dermatological 
literature has been carefully reviewed in order that the pages of this 
treatise may reflect its subject as completely as the limits of a single 
volume permit. The newer methods of diagnosis and treatment of 
proved value are incorporated, together with the results of research 
in etiology and pathology. Opinions of experienced dermatologists 
are freely quoted. The appended references are sufficient to give the 
inquiring student a guide to the most instructive literature of any 
particular subject. 

Many illustrations are reproduced from Dr. Hyde's treatise, and a 
large number of new ones have been added from the author's own 
collection, as well as through generous contributions of his colleagues. 
The author is deeply grateful to Drs. John A. Fordyce and George 
M, MacKee for placing at his disposal their excellent photographs, 
a number of which have been employed. He is further indebted to 
Drs. Howard Morrow, Otto II. Foerster, -I. F. Siler, W. -I. MacNeal 
and Fred Wise for photographs kindly furnished, and his thanks are 
due to the following gentlemen for the privilege of reproducing those 
heretofore used: Drs. John A. Fordyce, George Henry Fox, Howard 
Fox, A. I). Mewborn, Douglass W. Montgomery, Howard Morrow, 
Ernest E. Tyzzer, Stopford Taylor, M. L. Eleidingsfeld, David 
Lieberthal, Ernest L. McEwen and Heman Spalding. 



IV PREFACE 

For valuable assistance in abstracting the foreign literature, for the 
chapter on Hemorrhages, and for work incident to proof-reading, 
the author is greatly indebted to Dr. James Herbert Mitchell; and 
to his associate, Dr. J. Frank Waugh, for the chapter on the Wasser- 
mann Technique, and other assistance during the development of 
the work. 

He further desires to express to the publishers, Messrs. Lea & 
Febiger, his appreciation for encouragement during the preparation 
of the work and for the uniform courtesy extended while the pages 
were passing through the press. 

(). S. 0. 

Chicago, Ii.i... 1915. 



C X T E N T S 



Introduction 




I. Anatomy and Physiology of the Skin 


II. General Symptomatology . 


III. General Etiology 






IV. General Pathology . 






V. General Diagnosis . 






VI. General Prognosis 






VII. General Therapeutics 






Classification 







17 
17 
53 
tin 
71 
77 
93 
95 
136 



DISEASES OF THE SKIN. 



CLASS I. 

HYPEREMIAS AND INFLAMMATIONS. 

Erythema ■. 139 

Erythema Hyperemicum (seu Simplex) 139 

Erythema Scarlatiniforme 144 

Erythema Pernio 146 

Erythema Intertrigo 147 

Erythema Multiforme 149 

Erythema Nodosum 157 

Erythema Perstans 159 

Erythema Infect iosum 160 

Erytheme Miliaire Lcucogenique Prurigineux Chronique .... 100 

Erythema Elevatum Diutinum 160 

Granuloma Annulare 161 

Purpura Annularis Telangiectodes 162 

A Peculiar Progressive Pigmentary Disease of the Skin L65 

Urticaria 165 

Lichen Urticatus 168 

Urticaria Pigmentosa 175 

Angioneurotic Edema 179 

Prurigo 182 

Prurigo Nodularis I s "' 

Eczema 187 

Topical and Special Varieties - ); ! ; > 

Dermatitis 257 

Dermatitis Traumatica 257 

I dermatitis Venenata 258 

Dermatitis ( lalorica 264 



vi CONTENTS 

Dermatitis: — 

Dermatitis Congelationis 266 

Dermatitis Medicamentosa 267 

Feigned Eruptions 282 

Psoriasis 286 

Parakeratosis Scutularis 309 

Parapsoriasis 310 

Parapsoriasis en gouttes 311 

Parapsoriasis Lichenoide 312 

Parapsoriasis en Plaques 313 

Pityriasis Rosea 315 

Dermatitis Exfoliativa 319 

Dermatitis Exfoliativa (Wilson) 320 

Pityriasis Rubra (Hebra) 324 

Dermatitis Exfoliativa Neonatorum (Ritter) 328 

Dermatitis Exfoliativa Epidemics (Savill) 329 

Lichen Ruber 331 

Pityriasis Rubra Pilaris 331 

Lichen Planus 337 

Lichen Planus Morphoeicus (Crocker) 343 

Lichenification 349 

Lichen Nitidus 350 

Impetigo 351 

Impetigo Contagiosa 351 

Ecthyma 358 

Veldt Sore 360 

Dermal n is Vegetans 360 

Furunculu8 361 

Carbunculus 365 

Multiple Abscesses of the Skin of Infants 368 

Phlegmons Diffusa 369 

Dissection-wounds and Animal Poisons 370 

Gayle 370 

Anthrax 371 

Equinia 373 

Erysipelas 376 

Erysipeloid 381 

Solid Edema of the Face 382 

Dermatitis Repens 382 

Acrodermatitis Perstans 383 

Pompholyx 384 

Acrodermatitis Vesiculosa Tropica 388 

Dermatitis Gangrenosa 388 

Symmetrical Gangrene of the Extremities 391 

Dermatitis Gangrenosa Infantum 391 

Diphtheria of the Skin 394 

Herpes Simplex 394 

Herpes Zoster 398 

Dermatitis Herpetiformis 407 

Herpes Gestationis 409 

Impetigo Herpetiformis 412 

Pemphigus 415 



CONTENTS mi 

Pemphigus: 

Pemphigus Acutus U5 

Pemphigus Vulgaris . . 117 

Pemphigus Foliaceus 122 

Pemphigus Vegetans 126 

Hydros Vacciniforme 130 

Epidermolysis Bullosa Hereditaria 132 

Pellagra 134 

Acrodynia 444 

Exanthemata 444 

Rubeola 145 

Rotheln 149 

Scarlatina 450 

The Fourth Disease 456 

Variola 456 

Varicella 466 

Vaccina 468 

Rocky Mountain Spotted Fever 472 

CLASS II. 

HEMORRHAGES. 

Purpura 475 

Purpura Simplex 476 

Purpura Rheumatica 476 

Purpura Hemorrhagica 477 

CLASS III. 

HYPERTROPHIES. 

Keratosis Pilaris 479 

Ulerythema Ophryogenes 482 

Lichen Pilaris (seu Spinulosus) 483 

Keratosis Senilis 484 

Keratosis Follicularis 486 

Keratosis Follicularis Contagiosa 489 

Keratodermia Palmaris et Plantaris 490 

Mai de Meleda 494 

Keratodermie Blennorrhagique ' . 494 

Porokeratosis 496 

Angiokeratoma 498 

Acanthosis Nigricans 500 

Callositas 504 

Clavus 505 

Cornu Cutaneum 507 

Verruca 509 

Synovial Lesions of the Skin ... 515 

Nevus Pigmentosum 516 

Linear Nevus 519 

Giant Nevus 521 

tchthyosis 523 

Ichthyosis Bystrix . 525 



via CONTEXTS 

Ichthyosis: — 

Ichthyosis Congenita 526 

Ichthyosis Follicularis 527 

firythrodermie Congenitale Ichthyosiforme 531 

Keratolysis Exfohativa Congenita 531 

Scleroderma 532 

Morphea 535 

Morphea Guttata (White-spot Disease) 537 

Sclerodactylia 538 

Hemiatrophia Facialis 539 

Sclerema Neonatorum 543 

Edema Neonatorum 545 

Hereditary Edema of the Legs (Milroy's Disease 546 

Elephantiasis 547 

Acromegaly 553 

Myxedema 553 

Dermatolysia 556 

Cutis Verticis Gyrata 558 



CLASS IV. 

ATROPHIES. 

Atrophia Senilis 560 

Diffuse Idiopathic Atrophy of the Skin 561 

Acrodermatitis Chronica Atrophicans 563 

Atrophia Maculosa el Striata 564 

( rlossy Skiii 567 

Perforating Ulcer of the Fool 568 

Multiple Benign Tumor-like New-growths of the Skin 569 

Morvan'a Disease 570 

Kraurosis Vulvae 571 

Ainhum 573 



CLASS V. 

PIGMENT ANOMALIES 

Lentigo 576 

Chloasma 578 

Mongolian Pigment Spots 57-9 

Argyria 582 

Tattooing 582 

Blue Pigmentation 583 

Leuooderma 583 

Albinismus 583 

Vitiligo 584 

CLASS VI. 

NEW-GROWTHS. 

Cicatrix . 590 

Keloid 592 



CONTENTS r-. 

Keloid: 

( licatrioial Keloid 595 

Fibroma 597 

Paraffin Prosthesis ... 602 

Lipoma 605 

Adiposis I dolorosa 606 

Neuroma 607 

Myoma 608 

( Osteoma Cutis 610 

Angioma ; 611 

Nevus Vasculosus 611 

Telangiectasis 616 

Angioma Serpiginosum 618 

Granuloma Pyogenicum 621 

Lymphangioma 623 

Circumscriptum 624 

Molluscum Epitheliale 627 

Xanthoma 631 

Xanthelasma 636 

Diabeticorum 638 

Pseudo-xanthoma Elasticum 640 

Colloid Degeneration of the Skin 641 

Calcification of the Skin 642 

Adenoma of the Sabaceous Glands 643 

Multiple Benign Cystic Epithelioma 647 

Syringocystoma 649 

Xeroderma Pigmentosum 651 

Carcinoma of the Skin . 658 

Carcinoma Lenticulare 658 

Carcinoma Tuberosum 661 

Melanotic or Pigmented Carcinoma 661 

Paget's Disease 662 

Epithelioma 665 

Superficial or Discoid Epithelioma 665 

Morphea-like Epithelioma 666 

Rodent Ulcer 667 

Deep or Tubercular Epithelioma 669 

Papillary Epithelioma 670 

Endothelioma 673 

Topical Varieties 673 

Cancer of the Head (174 

( .nicer of the Lower Lip 675 

Cancer of the Genital Organs 670 

Cancer of the Extremities 677 

Cancer of the Mucous Surfaces 677 

Rhinoscleroma 687 

Tuberculosis Cutis ■ . . 690 

Lupus Vulgaris 690 

Tuberculosis Cutis Verrucosa 697 

Scrofulodermata 699 

Tuberculosis Cutis Orificialis 701 

Erythema Lnduratum 712 

Lichen Scrofulosum 715 



x CONTENTS 

Tuberculides 716 

Acnitis 718 

Folliclis 718 

Acrodermatitis Pustulosa Hiemalis 719 

Acne Scrofulosum 719 

Acne Cachecticorum of Hebra 720 

Lupus Erythematosus 721 

Multiple BenigD Sarcoid 733 

Syphilis 736 

Chancre 7:;7 

Syphilodermata 738 

Syphiloderma Maculosum 742 

Pigmentary Syphiloderm 744 

Syphiloderma Papulosum 746 

Small Acuminate Miliary Papular Syphiloderm 746 

The Lenticular Papular Syphiloderm 748 

Moisl Papules 751 

Palmar and Plantar Syphiloderm 754 

Syphiloderma Vesiculoeum 756 

Syphiloderma Pustulosum 757 

Small Acuminate Pustular Syphiloderm 757 

Large Acuminate Pustular Syphiloderm 758 

Hat Pustular Syphiloderm T.v.i 

Pustulo-ulcerative Syphiloderm 761 

Syphiloderma Bullosum 761 

Nodular Syphiloderm 762 

Gummatous Syphiloderm t 766 

Syphiloderma Hereditarium 769 

Lepra 801 

Granuloma Fungoides 816 

Leukemia Cutis 829 

Pseudoleukemia Cutis 832 

Sarcoma Cutis 833 

Non-pigmented Sarcoma 833 

Melanotic Sarcoma 835 

Idiopathic Multiple Hemorrhagic Sarcoma 838 

Oriental Sore 842 

Frambesia 845 

Verruga Peruana 848 

Gangosa 850 

Ulcerating Granuloma of the Pudenda 853 

CLASS VII. 

NEUROSES. 

Pruritus 855 

Pruritus Hiemalis 857 

"Prairie Itch" '. . 858 

Erythromelalgia 865 

Dermatalgia 867 

Causalgia 868 

Meralgia Paresthetica 869 

Trichotillomania 870 



CONTENTS X] 

(LASS \ III. 
PARASITIC Ml BCTIONS. 

Diseases Due to Vegetable Pabash 

Favus s ~' 

Trichophytosis s " s 

Trichophytosis Corporis 878 

Eczema Marginatum 881 

Eczematoid Ringworm of the Extremities . 881 

Dhobie Etch 882 

Trichophytosis Capitis ss l 

Trichophytosis Barbae 888 

Tinea [mbricata ( .)07 

Tinea Versicolor 909 

Erythrasma 914 

Pinta 915 

Mycetoma 917 

Actinomycosis of the Skin 921 

Blastomycosis 925 

Protozoan and Coccidoidal Infections 934 

Sporotrichosis 935 

Diseases Due to Animal Parasites. 

Pediculosis 938 

Pediculosis Capillitii 940 

Pediculosis Corporis 942 

Pediculosis Pubis 944 

Cimex Lectularis 946 

Grain Itch 947 

Copra Itch 950 

Brown-tail Moth 951 

Pulex Irritans 952 

Ixodes 954 

Other Insects: Mosquitoes, Gnats, Midges, Bees, Wasps 954 

Scabies 955 

Leptus 964 

Pulex Penetrans 965 

Dracontiasis '.Hit') 

( ysticercus Cellulosae Cutis 968 

Echinococcus 969 

Distoma Hepaticum 969 

Proliferating Cestode Larva 969 

Oxyuris Vermicularis 970 

l ncinarial Dermatitis 970 

Trypanosomiasis l .)7L 

Demodex Folliculorum 972 

Myiasis Cutanea 973 

Mucidae \)7'A 

(Estridse 973 

( Sreeping Eruption 974 

Craw-Craw ( .)7r> 



xii CONTENTS 

(LASS IX. 
DISEASES OF THE APPENDAGES. 

Diseases of the Sweat-glands. 

Hyperidrosis 977 

Anidrosia 981 

Bromidrosis 982 

Chromidrosis osi 

Uridrosis 986 

Phosphoridrosis ( .)S7 

Hematidrosis 987 

Sudamen 988 

Miliaria Rubra 989 

Miliary Fever . . 991 

Hydrocystoma . . 991 

Hydradenitis Suppurativa 994 

Granulosis Rubra Nasi 994 

I >I8E iSEB "i Tin: SeB \< BOUS ( rLANDS. 

Seborrhea 996 

Seborrhoic Dermatitis 1005 

Asteatosis 1013 

.Milium 1014 

Stratoiim 1010 

Comedo 1018 

Acne 1024 

Acne Rosacea 1039 

Acne Varioliformis ... 1045 

Diseases of the Hair and Hair-follicles. 

Hypertrichosis 1048 

Plica Polonica 1054 

Plica Xeuropathica 1054 

Atrophica Pilorum Propria 1054 

Pragilitas Crinium 1054 

Trichorrhexis Nodosa 1055 

Monilethrix 1058 

Trichonodosis 1059 

Piedra 1060 

Chignon Fungus 1061 

Piedra Nostras 1061 

Trichomycosis Flava, Nigra, and Rubra of Axillary Regions 1062 

Lepothrix 1063 

Trichostasis Spinulosa 1063 

Canities 1064 

Alopecia 1066 

Alopecia Congenita 1067 

Alop ia Prematura ' 1069 

Alopecia Pityroides 1070 

Alopeci. Senilis ■ 1071 



COA II. \ i > \ni 
Alopecia: — 

Alopecia Areata ... 1076 

Uopecia ( licatrisata los? 

Folliculitis Decalvana . 1090 

I dermatitis Papillaris < apillitii 1091 

Coccogenous Sycosis 1093 

Di>i: ^ses "i i be Nails. 

Onychauxis 1099 

Atrophica Unguium .1103 

Psoriasis of the Nails 1 107 

Eczema of the Nails 110s 

Syphilis of the Nails Ill") 

Onychomycosis 1113 

Trichophytosis Unguium 1113 

Onychomycosis Favosa 1113 

Congenital Abnormalities and Diseases of the Nails 1115 

Anonychia 1116 

Polydactyl 1116 

Syndactyl 1110 

Onych-heteropia 1116 

Diseases of the Mucous Membranes. 

Leukokeratosis Buccalis 1116 

Grooved Tongue 1120 

Transitory Benign Plagues of the Tongue 1120 

Erythema Migrans, or Wandering Rash 1120 

The Hairy Black Tongue 1122 

Cheilitis Glandularis ... 1123 

Cheilitis Exfoliativa . . ... .1124 

Fordyce's Disease 112.") 

Perleche 1127 



ABBREVIATIONS EMPLOYED IN THE WORK. 



Annales: Annales de Dermatologie et de Syphiligraphie, Paris. 

Archiv: Archiv fur Dermatologie und Syphilis, 1869-73; and since 1889. 

Brit. Jour. Derm.: British .Journal of Dermatology, London. 

Brit. Med. Jour.: British Medical Journal, London. 

Centralb.: Dermatologisches Centralblatt, Leipzig. 

( riorn. ital.: Giornale italiano delle malattie veneree e della polio, Milan. 

Jour. Aiimt. Med. ASSOC. : Journal of the American Medical Association. ( Shicago. 

Jour. Cut. Di>.: Journal of Cutaneous and Venereal Diseases, L882 87; Journal 
of Cutaneous and Genito-Urinary Diseases, L888 L902; Journal of Cutaneous Dis- 
. including Syphilis, since 1903, New York. 

Jour. mal. cutan.: Journal des maladies cutanees el Byphilitiques, Paris. 

Monatshefte: Monatshefte fur praktisohe Dermatologie, Eamburg. 

Vierteljahr. : Vierteljahresschrift fur Dermatologie und Syphilis, 1874 88. 

Zeitschrift: Dermatologische Zeitschrift, Berlin. 

Allbutl and Roll eston's System: A System of Medicine by Many Writers, edited 
by T. C. Allbutl and II. I). Rolleston. MacMillan & Co., London, L911. 

American Text-book: An American Text-hook of Genito-Urinary Diseases, 
Syphilis, and Diseases of the Skin, edited by L. Bolton Bangs and W. A. Bardaway, 
Philadelphia. 

Besnier's and Doyon's Notes: Besnier's and Doyon's note- in their French 
translal ion of Kaposi's treat ise. 

Crocker, Diseases of the Skin: Diseases of the skin, by Radcliffe Crocker, third 
edition, Philadelphia, L903. 

Duhring, Cutaneous Medicine: Cutaneous Medicine, Parts I and II, by Louis 
Duhring, Philadelphia, 1896. 

Internat. Atlas: The International Atlas of Rare Diseases of the Skin. 

Jarisch, Die Hautkrankheiten: Die Hautkrankheiton, Xothnagel's Specielle 
Pathologie und Therapie XXIV, Vienna, 1900 u. 1901. 

Kaposi, Diseases of the Skin: Pathologie und Therapie der Hautkrankheiten, 
ninth edition, 1899. 

La Pratique Dermatologique : La Pratique Dermatologique, Traite de Derma- 
tologie appliquee, edited by E. Besnier, L. Brocq, and L. Jacquet, Paris, 1900-1902. 

MacLeod, Pathology: Practical Handbook of the Pathology of the Skin, by 
J. M. H. MacLeod, London and Philadelphia, 1903. 

Manson: Tropical Diseases, by Sir Patrick Manson, London, 1910. 

Morrow's System : A System of the Genito-Urinary Diseases, Syphilology, and 
Dermatology, edited by Prince A. Morrow, New York, 1894. 

Mracek, Handbuch: Handbuch der Hautkrankheiten, edited by Franz Mracek, 
Vienna, 1901-1903. 

Scheube, Diseases of Warm Countries: Diseases of Warm Countries, by B. 
Scheube, translated by Pauline Falcke, edited by James Cantlie, Philadelphia, 1903. 

Stelwagon, Diseases of the Skin: Treatise on Diseases of the Skin, Henry W. 
Stelwagon, Philadelphia and London, 1913. 

Twentieth Century Practice: Twentieth Century Practice of Medicine, edited 
by Thomas L. Stedman, New York, 1896. 

Unna, Histoi tthology: The Histopathology of the Skin, P. G. Unna; English 
translation by Norman Walker, Edinburgh and New York, 1896. 



NTKODl CTION. 



Preceding the description of the various diseases of the skin, 
several chapters are devoted to subjects of vital interest to the student 
of dermatology, and which, if mastered, will materially simplify the 
study of the individual diseases. Without a good working knowledge 
of the microscopic anatomy and of the physiology of the skin, an under- 
standing of the pathological changes which occur in disease is ren- 
dered more difficult. In the description of cutaneous diseases in the 
text, the different symptoms are described in terms entirely different 
from those used ordinarily, and the student is therefore urged to 
master the chapter devoted to General Symptomatology. In the 
chapter on General Pathology, many terms are defined and patho- 
logical processes common to a large number of diseases are outlined 
which greatly facilitate the special study taken up later. In the chapter 
on General Diagnosis, special methods pertaining to cutaneous disease 
are detailed, such as the Wassermann test for syphilis, Xoguchi's 
luetin test for syphilis, and the tuberculin, von Pirquet, and other 
tests for tuberculosis, in addition to much other information of value 
in the general and special examination of the patient. The chapters 
on General Etiology and Prognosis should also receive attention, 
and the one devoted to General Treatment is of value both for 
reference on special occasions, and also to obtain some knowledge of 
drugs, chemicals, and other means found useful in the management 
of cutaneous diseases. Among other methods described here will 
be found radiotherapy, which includes .r-rays and radium; photo- 
therapy, vaccine therapy, and the technique for treatment with 
liquid air and solidified carbon dioxide. 



I. ANATOMY AND PHYSIOLOGY OF THE SKIN. 



Till': skin is essentially one of the vital organs of the 1 body, per- 
forming functions necessary to health and life. It is closely associated 
with underlying structures, and by its situation is brought into inti- 
mate relation with the external world. The skin is a complex, elastic, 
and sensitive organ, varying greatly in different conditions of climate, 

17 



18 ANATOMY AND PHYSIOLOGY OF THE SKIN 

age, sex, health, and race; and varying also in the characteristics 
exhibited in different localities upon the same individual. Thus, in 
color there is a wide range between the fair skin of the blonde and 
the black skin of the negro, between the rosy pink of the infant's 
palm and the dark-brown hue of the genital region of the aged. The 
skin varies also in pliability and thickness, being delicate and lax 
over the eyelids, the lips, and the prepuce, and much thicker and 
more firmly attached over the palms and soles. 

Ridges and Furrows. Viewed externally, the skin is seen to be 
traversed by superficial and deep furrows, which vary in arrange- 
ment and siae according to their situation. They are formed by the 
attachment of the skin to the deeper structures, by the movement 
to which one part is subjected, and by the arrangement of the fibrous 
structures of the corium. In some situations (the palms and soles), 
the fine furrows have a regular arrangement and run parallel with 
each oilier. The pattern thus outlined i> constant in the individual, 
of which fact use is made in the identification of criminals. Between 
these fine furrow s arc ridges dotted with numerous depressions 
representing the openings of sweat-pores. r l ne entire body is traversed 
by fine furrow.-, which form an irregularly diamond-shaped network. 

Coarse furrow- are found chiefly in situations where the skin is 
subjected to movement, such as about the joints, and they are due 
to the fixation of the skin to deeper structures by fibrous bundles. 
It is in such situations that fissures occur, when the normal pliability 
is lost through inflammatory thickening. The shape of many of the 
lesions of the skin is determined by the ridges and furrows above 
described. 

The skin is divided, on account of anatomical differences, into 
three general layer s: the epidermis_qr_jarticle; co rium or true skin; 
and subcutaneous tissue or Eypoderm In these various layers are 
found the coil- and sebaceous-glands, blood-vessels, lymph-vessels, 
muscles, pigment, nerves, and the appendages of the skin — the hairs 
and nails. A clear conception is best had in a study of these component 
parts by progressing from within outward. 

Subcutaneous Tissue (Stratum Subcutaneum, Panniculus Adi- 
jjosus). — The subcutaneous tissue, or hypoderm, is differentiated 
from the corium between the third and fourth months of fetal life. 
It is a structure serving a mechanical purpose as a receptacle for fat, 
and for the support of vessels and nerves passing from the tissues 
beneath to the corium above. It contains, also, coil-glands, some of 
the hair-follicles more deeply situated than their fellows, and Pacinian 
corpuscles. There is no distinct boundary line between the upper 
limits of the subcutaneous tissue and the overlying corium, to which 
it projects columnar masses of fat, extending obliquely to the coil- 
glands and the hair-follicles above, often with lateral, horizontally 
disposed prolongations of similar shape. It is built up of loose con- 
nective-tissu bundles, which are attached to the aponeuroses, fascise, 
and the membranes lying beneath. 



Si /;< i r LA EOUS TISSUE 



I'.i 



Fig. ! 




Section of skin from the palm of i he hand, magnified 150 diameters: a, stratum corneum; 
a', its superficial Layer; />, stratum lucidum; c, stratum granulosum; <7, stratum mucosum 
(rete); e, pars papillaris of the corium, loops of capillary vessels showing in vascular 
papillae;/, para reticularis of the corium, showing coarse interlacing connective- tissue 
bundles; <i, transverse section of tin' Latter; h, double-contoured nerve-fibers passim: 
to tactile body; /, coil-glands; fc, ducts of coil-glands; /, sweat-pores passing to surface 
of the epidermis; ///, arteries of the skin terminating in capillaries; n, veins of the skin 
forming plexuses; o, fat-cells, encompassed by capillary loops, in relation with coil- 
glands (the capillaries of the hitter are purposely omitted in the drawing); i>, obliquely 
and transversely divided bundles of connective-tissue fibers of the corium and subcu- 
taneous t issue. 



20 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



The subcutaneous tissue is attached firmly to the skin over the 

extensor surfaces of the articulations, the palms and soles, and the 
groins by short, coarse bundles, between which are single or multi- 
locular spaces lined with endothelia secreting a mucoid fluid. Some 
of these are congenital; others result from evolution later in life. 
They are most frequent and largest where necessary movements 
occur, as where the skin is stretched over a hone or tendon. These 
spaces constitute the bursa' mucosa 1 . In the eyelids, the penis, the 
scrotum, and the auricle of the ear, the attachment to the skin is 
by loose, delicate connective tissue, containing no fat-globules." In- 
other situations, the fibrous tracts are arranged obliquely. They 
admit by their extension of various degrees of pliability, and inclose 

Vic. L' 




Subcutaneous fat-tissue, the fat having been extracted with turpentine: B, bundles 
of fibrous connective tissue, carrying injected blood-vessels; C, capsules of fat-globules, 
with oblong nuclei. Magnified 500 diameters. (After Heitzmann.) 

rhomboidal spaces containing more or less numerous fat-globules. 
These spaces are divided into lobes by fibrous tissue called trabec- 
ular and the lobes are again subdivided by fibrous septa into lobules. 
In addition to these collections of fat, columns extending obliquely 
from this situation to the bases of hair-follicles and coil-glands have 
been described by Warren. 1 They are known as columnce adijxjsce. 

The deposit of fat in the body is reduced greatly in all diseases 
productive of emaciation, but never wholly disappears during life. 
In cases of obesity, fat is deposited in excess of normal limits, and it 
may then be concerned in the production or the aggravation of disease. 



1 Boston Med. and Surg. Jour., April, 1877. 



THE CORIV XL 21 

It is due largely to the greater or lesser volume of the panniculu 
adiposus thai the natural outlines of the body are made to the eye 
graceful and attractive or the reverse. 

The Corium (Derma, Cutis, Cutis Vera, or True Skin). The corium 
is a mesoblastic structure, made up largely of connective tissue and 
cellular elements. It is rich in blood-vessels and capillaries, especially 
in the papillary layer, and contains many nerves, nerve-endings, 
and terminal nerve organs. It also contains lymphatics, small muscle- 
fibers, hairs, sweat-glands, and sebaceous-glands. 

The fibrous elements are of two varieties: collagen and elastin. 
The collagen occurs as bundles of fibers held together by a semifluid, 
interfibrillary substance. The fibers are about :; ._,',, u of an inch 



Fig. 3 




Vertical section of the skin showing: a, epidermis; b, erector pili muscle; d, oolumnae 
adiposae; c, coil-gland suspended in the columnar adiposoe; h, sebaceous gland; p, hori- 
zontal prolongations of the column; /, fibrous bundles of the corium; g, panniculus 
adiposus; fc, band of fibrous tissue extending into the panniculus adiposus. (After 
Warren.) 



(O.Tfyu) in breadth, and according to Clarkson (quoted from MacLeod) 
are made up of fibrils that are approximately -„,',„„ to 26060 °* 
an inch (0.05/x to 0.12/*) thick. The collagenous bundles are only 
slightly extensible, but as their arrangement presents a wavy appear- 
ance, on longitudinal section, they admit of stretching of the skin. 
The individual fibers do not branch, but such an appearance is simu- 
lated by the joining of parts of different bundles. 

The elastic libers (elastin) occupy the entire corium and extend 
throughout the subcutaneous tissue. These fibers, by anastomotic 
branches, form a network which surrounds the collagenous bundles 
and all the other elements of this region, acting as a supporting frame- 
work. These fibers vary in thickness from imperceptible fineness up 



>)•) 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



to llyu in breadth (Stohr) and have little elasticity. They are the 
first to rupture when the skin is stretched, as is demonstrated in 
the lineoB albinnitrs, and their chief function appears to be that of 
support. 

The cellular elements of the corinin consist of connective-tissue 
corpuscles, vacuolated cells (Schafer), mast-cells, and migratory 
blood-cells. (Description of these cells, p. 74.) The fibers and 
bundles of connective tissue are coarsest toward the subcutaneous 
tissue, and finest toward the outermost portion, which comes in 
contact with the epidermis above. They form the mesoblastic portion 
of the hair-follicle, the capsules around the coil-glands, and the layers 
which surround their ducts. 

Fio. I 




Vertical section of skin after injection (from beneath) of areolar tissue with Berlin blue: 
a, epidermis; /, corium; g, panniculus adiposus; /<. sebaceous gland. I Aiter Warren.) 



Corresponding with their anatomical structure, the upper and 
lower portions of the corium are called respectively the "papillary 
layer" and the "reticular layer." There is no sharp dividing line 
between these layers, the pars reticularis passing gradually into the 
pars papillaris above and into the subcutaneous tissue below. 

Pars Reticularis. — The reticular layer of the corium is made up of 
interlacing connective-tissue bundles, which are coarser below and 
separated by larger spaces. The bundles become finer and the spaces 
smaller toward the surface. 

Pars Papillaris. — The papillary layer lies in contact with the rete 
above, and is connected below with the deeper reticular portion of 
the corium. Between the rete and the papilla? of the corium, a 
hyalin substance is interposed, which is supposed to be identical 
with the cement substance surrounding and separating the fibrillse 
of the corium. The basal membrane, once thought to be stretched 
between the rete mucosum of the epidermis and the papillary 



/' [RS I'M- 1 I.I. IRIS 23 

layer of the corium, cannot be demonstrated to exist. Viewed 
obliquely with an amplification of about 300 diameters, it will 
be seen that long, slender filaments from the prickle-cells of the 
mucous layer of the epidermis encircle in ;i spiral direction both 
nervous and vascular papillae. At the apices of t he latter, t hese threads 
completely surround the connective-tissue fibers. 

The name of this portion of the corium is intended to describe its 
chief characteristic, the existence of numerous digital prolongations 
or nipple-like prominences of the corium, made up of delicate con- 
nective-tissue fibers, which do not interlace 1 and which are abundantly 
provided with nuclei. The papillae spring- each from a single, or 



Fig. 5 




Vwfmm 



Vascular and nervous papillae: a. vessel; b, nervous papilla; c, vessel; d, nerve-fiber; 
e, corpusculum tactus; /, transversely divided nervous filaments; g, epithelia of rete. 
(After Biesiadecki.) 



several from a common, ovoid base. Their bulbous, conical, or blunt 
apices reach into the rete, which also dips down between them in 
prolongations termed u rete-pegs." The papillae vary in size in dif- 
ferent parts of the body, and also in their disposition and shape, being 
in places arranged in linear series, and in others in concentric whorls, 
with definite centres, thus producing corresponding furrows, visible 
to the naked eye as markings upon the outer surface of the epidermis. 
The largest are found on the palms and soles and over the inner 
faces of the digits. It has been estimated that 100 are developed 
within each square millimeter of the body surface. 

In horizontal sections of the skin, the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can he recognized 



24 ANATOMY AND PHYSIOLOGY OF THE SKIS 

a centrally and transversely or obliquely divided capillary loop. 
Between these areas is seen the interpapillary reticulum of the 
mucous layer. 

The growth of the rete downward and of the corium upward results 
in mutual effects of pressure and counter-pressure, the equilibrium of 
which is constantly adjusted by the mechanical and vital necessities 
of such union. 

When the papilla* are completely exposed, after removal of the 
overlying cement substance and of the epidermis above, their exterior 
surface is seen to he uniformly and delicately marked with series 
after series of alternating furrow- and ridges, more or less concen- 
trically disposed. Into the grooves are admitted corresponding denta- 
tions, that can he recognized on the under surface of the layer of 
epithelial cells next to the corium. They may, however, be the 
furrows left after separation of the long prickles wrapped about the 
papillae and traceable to the mucous layer. 

Fig. 6 













. ■ ,; 


-jfrll 


■■.Pi 





./ 



Scalp of a negro — horizontal section: R, rete mucosum; Pi, row of columnar epithelia 
(cut obliquely) supplied with dark-brown pigment-granules; Pa, papilla (cut trans- 
versely) ; D, derma. Magnified 500 diameters. (After Heitzmann.) 

Two varieties of papilla 1 are distinguished, the vascular and the 
nervous. The former contains the terminal loops of a minute artery 
and vein, and the latter the terminations of medullated nerve-fibers. 

The greater number of the papillse are of the vascular variety, 
being traversed by a vertically disposed loop of vessels, consisting 
of an arterial and a venous capillary. The office of the vascular loop 
is evidently not merely to supply nutriment for the epidermis above, 
but also to provide for the cooling of the blood when brought in large 
quantities to the surface of the body. Occasionally, two or more of 
such loops can be recognized in a single papilla. 

The nervous papillse contain the tactile corpuscles, which serve an 
important purpose in providing for the sensibility of the integument 



RETE MUCOSl M 

Ultimate terminations of nerves can !><■ seen in the papillae largely 
occupied with the corpuscles of touch. 

Lines of Cleavage. Puncture of the skin with a rounded instru- 
ment leaves an irregularly longitudinal slit. This phenomenon occurs 
as the result of the arrangement of the connective-tissue bundles 
and fibers of the corium. Dupuytren 1 studied this in the -kin of the 
palm, and Langer and Ileitzinanir later mapped out the special 
directions over the entire body in which these lines occur. 

The Epidermis [Scurf Skin or Cuticle). The epidermis is the most 
external of the several layers of the skin, being in close contact on 
one side with the corium and exposed on the other to the atmosphere 
by which it is surrounded. The latter surface is therefore relatively 
drier, while the former is constantly moistened by fluids from the 
vessels which ramify beneath it. It is of epiblastic origin and made 
up of superimposed strata of epithelial cells, and varies in aspect 
and thickness according to its anatomical situation and the age of the 
subject. 

The epidermis is composed of the following principal layers, named 
in order from within outward: the stratum mucosum, the stratum 
granulosum, the stratum lucidum, and the stratum corneum. All 
the cells composing these various layers are derived from the basal 
layer of the rete. Besides these, Ranvier and others recognize a 
stratum germinativum, a stratum filamentosum, a stratum inter- 
medium, and a stratum disjunctum. 

Rete Mucosum [Mucous Layer, Prickle Layer, Stratum Mucosum, 
Lute Malpighii or Malpighianum). — This is the deepest of the epider- 
mal layers, and rests upon the corium below. It is generally designated 
as "the rete." The corium is intimately united with it by a series of 
interdigitations, which are commonly described as prolongations of 
the derma into the substance of the rete; but it is equally true that 
the rete sends down prolongations (the "rete-pegs") into the derma. 
The two, in the need of an intimate union to resist friction and to 
insure vascular supply, are thus closely locked together. 

The stratum mucosum is built up of nucleated epithelial cells, 
chiefly of polyhedral shape. These cells are masses of granular 
protoplasm, living matter, which by their relation to one another 
form a protoplasmic network enveloping the entire surface of the 
body and lining all channels and cavities in direct or indirect communi- 
cation with the surface. There are lymph-spaces between the epithelia, 
from which the nutritive fluids are conveyed to the cells, and the 
individual cells are united by delicate protoplasmic threads, called 
prickles, spines or thorns. The epithelia are not provided with either 
blood-vessels or lymph-vessels, but arc supplied with a large number 
of nerves, which, in the shape of very minute beaded fibers, traverse 
the intercellular substance, and which arc in direct communication 

1 I'dnT die Vi rlct Eungen (lurch Kriegswaffen aua dex Franz, 1836, p. 27. 
- An-hiv. 1890, xxii. p. 3. 



26 



AXATOMY AM) I'll YSIOLOGY OF THE SKIN 



with the reticulum of living matter within the protoplasmic bodies 
themselves. 

Next to the curium is a layer (basal layer, stratum germiruitimm) 
of cells, columnar in form, often largely provided with pigment, and 
arranged with their long axes nearly at right angles to the plane of 
that portion of the corium upon which they are superimposed. The 
cells of this layer are dividing constantly by mitosis, the (laughter- 
cell- pushing outward to form the succeeding layers. The entire 
epidermis is thus derived from this single (occasionally double) row 
of columnar cells. More externally, the cells are rounded or cuboidal 
in form, with large, distinct nuclei. They are not arranged in definite 
strata except in the outermost layers, where the cells become more 
flattened and elongated (stratum jilumeuiosum). 









Prickle-cells from a condyloma (magnified about 02.", diameters): a, cavity of cell- 
nucleus; h nucleus; r, nucleolus; '/, prickles — these are greatly developed on the proto- 
plasm of the cells. The dots on the surfac<,- of the protoplasmic mass represent the 
appearance of the prickles when directed toward the eye of the observer. Some of the 
protoplasmic threads are seen pa.ssimz from one cell to another. 



Langerhan's Cells. — These are elongated, irregularly stellate, non- 
nucleated bodies, found chiefly in the deeper parts of the rete. They 
have been looked upon as pigment-cells devoid of pigment, as wander- 
ing cells, lymphoid cells, and as colorless tissue-corpuscles. 

Stratum Granulosum (Granular Layer). — The stratum granulosum 
of the epidermis lies immediately above the stratum mucosum, and 
is built up of three or four rows of horizontally disposed cells, united 
to one another by short, broad threads, and containing granules. 
Between the cells, the spaces are so contracted that nutritive fluids 
cannot easily filter outward, and the nuclei of the cells are usually 
shrunken. These cells have been classified and studied by Ranvier, 
Kolliker, Waldeyer, and others. According to these observers, the 
roundish granules which give this layer of the epidermis its name and 



STR I ri \i CORh El \l 

peculiar appearance consist of keratohyalin, a substance which plays 
a part in the process of cornification. These granules fir I appear 
in the neighborhood of the nuclei of some of the large prickle-cells 
in the rete, 1 >i 1 1 they arc besl studied in the granular layer, the cells 
of which are often completely filled with them. Keratohyalin i.> 
a solid or semisolid substance, being chemically closely allied to 
hyalin. According to I una, the color of the skin of the white races 
depends upon this layer alone. 

Stratum Lucidum (Septum Lucidum) of Oehl lies immediately above 
the stratum granulosum, and appears under the microscope as a 
delicate, brightly colored line consisting of two or three rows of trans- 
versely disposed, glistening epithelia, differing in translucency from 
those situated on either side. The stratum lucidum thus marks with 
tolerable distinctness the boundary lines of the rows of cells above 
and below it. Its cells no longer contain the granules of keratohyalin, 
conspicuous in the stratum granulosum below, but in their place have 
acquired an oily-looking substance termed eleidin. Eleidin, though 
oily-looking, is not a fatty substance. It differs from keratohyalin 
physically and chemically, but MacLeod suggests that it may be a 
derivative of keratohyalin. 1 

The cells of the uppermost layer of the stratum lucidum have been 
termed the stratum intermedium by Ranvier, for the reason that 
they take a reddish stain after treatment with picrocarmine. In 
this layer the process of keratinization is first detected. 

Stratum Corneum {Horny Layer) of the epidermis is its outermost 
and widest layer. In its lower portion, the cells still retain to a degree 
the shape of the cells below, indicating their relationship. Nuclei 
exist in this layer only as shriveled and inconspicuous relics. Occa- 
sionally, on the edges, rudiments of prickle-cells may still be recog- 
nized. More externally, the dried, lifeless, horn-like plates of which 
this layer is composed become mere cornified shells, generally lying 
in horizontal strata and becoming more curled and wrinkled as the 
surface of the skin is reached, often being imbricated, but preserving 
the polygonal outlines of epithelia relieved of the forces of pressure 
and counter-pressure exerted in the deeper part of the epidermis. 
Xo pigment is present in this layer, except in the colored races. The 
cells contain a fatty material, which adds to the suppleness of the 
skin and prevents undue evaporation, and also absorption from the 
outside. The hard, dry character of the cells is due to a resistant 
substance termed keratin, which has replaced the keratohyalin of 
the stratum granulosum and the eleidin of the stratum lucidum. 
Keratin is insoluble in 50 per cent, dilution of mineral acids, and 
resists digestion in a solution of pepsin containing weak hydrochloric 
acid, but is soluble in weak alkaline solution. 

After digestion with pepsin and trypsin, the horny cells may be 
seen to be connected by more or less persistent threads, forming a 

1 Cf. MacLeod's Pathology lor complete discussion and description of keratohyalin 
and eleidin, p. 61. 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN 

large-meshed reticulum, with strands formed from a double row of 
cornified filaments united by short, horny bridges. 

St rat hid Disjunctum. — This is the most superficial layer of the 
stratum eorneum, and only differentiates by staining methods. 

Spiral Fibers.-- Herxheimer's 1 spiral fibers arc found chiefly between 
the cells of the rete and the basal layer of the epidermis. They are 
most abundant normally in the lower part of the rete, and become in- 
creased in number in inflammatory conditions. They lie for the most 
part parallel with the long axes of the rete-cells. They sometimes 
arc found between the cells of the inner root-sheath of the hair- 
follicle. Opinion differs as to their nature. Jadassohn, Ehrmann, 8 
MacLeod 5 and others believe them to be spiral> of fibrin. This seems 
probable, since they are increased in number when an inflammatory 
reaction is present, and since they occupy the lymph-spaces between 
the cells and in size correspond with these spaces. They have in 
the past been regarded as elastic fibers protruding from the corium 
below; as part> of a canal system for the conveyance of nutriment 
to the cells of the epidermis, etc. 

Cornification. The process by which the epithelial cell from the 
basal layer of the rete becomes transformed into the hard, resistant 
cell of the stratum corneuni has been studied ;it length, and the part 
played by the keratohyalin of the granular layer and eleidin of the 
stratum luciduin in the formation of keratin has caused much contro- 
versy. While, as a rule, when oornifieat ion is perfect both keratohyalin 
and eleidin are present normally, and when these two are absent or 
imperfectly formed cornification is incomplete, "yet cornification may 
occur without the intercurrence of these substances. MacLeod con- 
siders keratohyalin as "a separation product of the protoplasm of 
the cell which appears as the vitality of the cell is diminishing; 
eleidin, a further product of the same substance; and the ultimate 
product of both is probably the fatty or waxy substance which is 
present in the horn cells." "The intercellular bridges or prickles 
would, according to this hypothesis, become hardened into keratin 
by an inherent power of their own, in much the same way as the 
fibro-vascular system of a leaf at the fall of the year becomes hardened 
into a brittle leaf skeleton." 

Blood- Vessels. — The skin is richly supplied with blood-vessels, par- 
ticularly on its flexor surfaces. It is customary to describe the blood- 
vessels in the skin as consisting of an upper and a lower plexus or 
ridge-net. A more simple explanation of the vascular supply than 
that formerly made has been given by MacLeod. 4 Practically 
the entire supply comes from a system of blood-vessels situated in 
the subcutaneous tissue. There is in addition a horizontal plexus 
located in the papillary layer of the corium, the latter being formed 

1 Arch., 1889, p. 645 

2 Arch., 1892, Erganzungsheft, i, p. 307; and Monatshefte, 1897, xxiv, p. 549. 

3 MacLeod's Histopathology of the Skin, 1903, p. 59. 
* Ibid. 



NON Mi: hi i.i. [TED FIBERS 29 

L ,i .cries of arteries and capillaries running more or le vertically 
from the subcutaneous plexus and branching horizontally in tin 
region. Taken as a whole, the larger arteries divide and subdivide, 
eventually becoming capillaries, which join venous capillaries and 
return by anastomosis to the subcutaneous veins by the junction of 
the various tributaries, thus following a return course similar to thai 
taken by the arteries. In the subcutaneous tissue the course of the 
vessels lies between the lobes and lobules, and after dividing into 
small branches these surround and supply the fat-cells. A plexus 
of vessels, chiefly derived from the subcutaneous group, is also 
found about the coil-elands, the remainder of the sweat-apparatus 
being supplied largely from vessels in the corium. The sebaceous 
glands, hair-follicles, and arreetores pilorum are also freely ap- 
plied with plexuses of vessels. The major portion of the vessels in 
the subcutaneous tissue have an endothelial lining and a muscular 
and adventitious eoat, while those of the corium are supplied with 
an endothelial lining only. 

From the horizontal plexus in the papillary layer loops are sent 
to each papilla. These are either single or compound, the returning 
venous capillary being about four times the diameter of the arterial 
capillary. Special venous sinuses lined with endothelium are found 
in the tips of the fingers and toes, the lobes of the ears, the nostrils, 
the lips, and the nail-beds. In inflammatory and other pathological 
conditions of the skin, most marked perivascular infiltration occurs 
in the regions about the glands and hair-follicles and in the papillary 
layer, thus indicating the distribution of the greatest number of 
vessels. 

Nerves. — The skin, in view of the number and mode of distribution 
of its nervous elements, may be regarded as a vast area of sensitive 
nerve-terminals. Non-medullated and medullated nerve-fibers, each 
in places being substituted for the other, are supplied to the skin from 
horizontally disposed bundles of nerve-twigs in the subcutaneous 
tissue. These fibers traverse the corium in connection with the 
blood-vessels, and become finer as they ascend, until they form a 
subepithelial plexus below the epidermis. 

Non-Medullated Fibers are exceedingly delicate fibers, penetrating 
in great abundance to the epidermis between the epithelia, and are 
not to be confounded with the migratory cells found in this situation. 
Mere, traversing the intercellular substance by the side of the juice- 
spaces, these fibers either terminate between the prickle-cells as 
ultimate bulbous terminations of finely beaded fibrillar, or penetrate 
the epithelia themselves in pairs. Each prickle-cell is supplied with 
a pair of these beaded filaments, which may be either applied to the 
DUcleus of the cell or be seen to encircle the nucleus more or less 
completely. Above the stratum granulosum these nervous threads 
cannot be recognized. 

Similar nerve-filaments are supplied to the sheaths of the hairs 
and the ducts of the coil-elands. It is bv means of these numerous 



30 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



and delicate fibers that the perception of sensation in the skin is 
accomplished. 

Motor filaments are also distributed to the sheaths of the blood- 
vessels (vasomotor nerves), in which they are finally lost. Other 
motor filaments supply the muscles, and trophic nerves are dis- 
tributed to all the secreting organs of the skin and to all its proto- 
plasmic formations. 

Medullated Nerve-Fibers of the skin in one or several loops pass 
upward into the papillae, and then turn backward to the subpapillary 
region. Some of these fibers, after such reversion, again ascend to 
an adjacent papilla; others arc supplied to the Pacinian and tactile 
corpuscles. 

Fig. 8 





n.g.p 



Pacinian body, after silver stain- 
ing, showing superimposed endothe- 
lial layers. (After Renault.) 



& ction of Pacinian body from a duck's bill: 
</. /.. lamellar envelope; g.h, hyaline zone of the 
lamellar envelope; b.t, terminal bulb of . the 

nerve; g.p, n.g.p, layer investing the cavity of 
the body. (After Renault.) 



Pacinian Corpuscles (named from the anatomist Pacini), also called 
Corpuscles of Voter, exist subcutaneously only upon nerves intended 
for cutaneous supply. They are ovoid bodies, two or more milli- 
meters in diameter. Each corpuscle consists of a series of concentric, 
nucleated, vascular capsules, arranged after the manner of the cap- 
sules of the onion, more closely united at the periphery than at the 
centre, and surrounding a protoplasmic core. The medullated nerve 
to which the body is attached gradually loses its myeline envelope, 
and terminates in the centre of this core, after traversing the greater 
part of its axis, in one or several minutely club-shaped filaments. 
The myeline sheath is lost in the tissue of the concentric capsules. 
The nerve may, after supplying one capsule, penetrate a second or 



PAC1 Y/.I.Y CORPUSCLES 



11 



even ;i third. In such cases the nerve regains it.^ sheath as it i ue 
From the corpuscle ;it its opposite pole. Robinson believes thai 
the nerve forms ;i plexus or loop within the corpuscle, and escapes 

from it ;it one of its poles. 



I 1 

m £j 
m |SH 

i 
i 

it 

1> 




H 


e 


■NESR 


i ' 






ft 




L- K 

P K 


a ^ 

c 





Section of a papilla ^t ill covered by a portion of the stratum mucosum and contain- 
ing a tactile body (from the skin of a finger). The corpuscle of Meissner is seen to 
consist of minute lolmles, made up of a homogeneous protoplasm, with numerous ova] 
nuclei and nervous fibrillffi wound in a spiral direction about the mass of the corpuscle. 
The extension of the fibrilUe to the mucous layer is shown. The courses of the nerve- 
filaments are demonstrated to be: (1) the axis-cylinders of one or two double-contoured 
nerve-fibers, splitting into their original fibrilUe on arriving at the corpuscle, winding 
about the latter in characteristic spirals, and passing to the palisade-layer of the prickle- 
cells of the rete, between which, on account of the long prickles of the latter and the 
general resemblance of the two in thickness and contour, it is difficult to trace them 
further; (2) filaments from another double-contoured nerve-fiber (//) pass directly to the 
inferior layer of cells in the rete without establishing relations with the tactile body; (3) 
fibrillffi derived from the network of nervous fibrillffi in the pars papillaris of the corium 
(A.'), also passing more or less directly to the stratum mUCOSUm; a, cells of the rete: i>, 
prickles of the Latter; c, body of papilla; d, nuclei of connective tissue forming papilla; 
', protoplasmic part of the tactile body with its nuclei; /, fibrillffi of the corpuscle; g, 
double-contoured nerve-fibers directly supplying the rete; fc, nervous fibrillar derived 

from the network in the pars papillaris; /, nervous fibrillffi entering the epidermis 
'"'tween the rete-cells Leaving the corpusculuni tactus at ///. 



The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since 
these bodies are most numerous in the subcutaneous tissues of the 



32 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



nipple, the penis, the digits, and in parts similarly sensitive. These 
corpuscles bear an analogy to the organ of vision, each body having 
a capsular character; each being provided with a special nerve-fila- 
ment, which enters the corpuscle at one pole; each also receiving its 
impressions at the extremity of the capsule opposite that at which 
it receives its nervous supply. 

According to Krause, the Pacinian corpuscles aid in the appre- 
ciation of impressions produced by pressure and traction. Whether 
specially concerned in distinguishing sensations of heat, cold, moisture, 
pressure, traction, or weight, it is evident that they contribute but 
little, if at all, to the perception of ordinary impressions upon the 
skin, and they are not known to play any part in cutaneous diseases. 

Fig. 10 




Transverse section of nervous papilla surrounded by cells of the stratum mucosum: 
o r protoplasmic lobules of the corpusculum tactus; b, nervous fibrillar spirally wound 
about the latter; c, transverse section of double-contoured nerve-fibers; d, cavity of 
nucleus (out of focus). 



Tactile Corpuscles (Corpuscles of Meissner or of Wagner) are ovoid 
bodies found in about one in four of the papillae in the pars papillaris 
of the corium. Each corpuscle is composed of from one to three 
capsules. Minute lobules of a homogeneous protoplasm with oval 
nuclei are found in each. These corpuscles receive medullated nerve- 
fibers, and are made up of closely compressed, flat, connective-tissue 
fibers with minute nuclei, wdiich are so packed together as to form 
a spindle-shaped mass occupying the greater part of the papilla in 
which each corpuscle is found and surrounded by a somewhat denser 
connective-tissue capsule. The myeline sheath of the nerve-fibers 



L) M I'll \ TIC VESSELS 

is lost in the fibrous tissue <>f the corpuscle. Externally viewed they 
e< in to be transversely striated. 

The axis-cylinder of the nerve-filameni distributed to each corpu cle 
divides into numerous delicate nerve-t breads, which in pari encircle 
the corpuscles and also penetrate within. Bach corpuscle is provided 
with an afferent and an efferent nerve, the former approaching the 
corpuscle from the subpapillary region and entering at or near its 
base. Occasionally the afferent fiber is furnished by an adjacent 
papilla. As the filament that enters the corpuscle frequently divides, 
two or more efferent fibers may then escape from it. Afferent fibers 
reach the rete above after encircling the tactile corpuscles; other-, 
side by side, arrive at the rete without coming into contact with the 
former. 

The discovery of nerve-filaments in and among the epithelia of 
the epidermis in such abundance as to provide fully for tactile sen- 
sation in the skin leaves the exact function of these eorpuscle> in 
partial obscurity. There can be little doubt, however, as to their 
association with the perception of certain qualities of foreign bodies 
with which the skin may be brought into contact. 

Touch-Cells. — IMerkel's touch-cells are oval, nucleated bodies found 
in the lower animals, but also in man. They are supposed to be 
connected with the ultimate nerve-fibers. They resemble cells in 
a mitotic state, and are found in the upper parts of the corium as 
well as the epidermis, and in regions in which the tactile corpuscles 
are few, as over the abdominal surface. 

Corpuscles of Krause {Bulb-Corpuscles: Kolbenkorpercheri) are rounded 
or oval-shaped bodies formed of a connective-tissue envelope and a 
non-nucleated bulb, to which some delicate nerve-fibers penetrate. 
These bodies are found chiefly along the borders of the lips, over the 
glans penis, the clitoris, and the tongue. 

Lymphatic Vessels. — The skin in all its parts is provided with a 
closed system of lymphatic channels, designed to subserve the neces- 
sities of the important processes of absorption, and is traversed by 
lymph, the currents of which are continuously directed to the large 
vessels of the structures beneath the skin. These channels include: 
first, juice-spaces, provided or not with independent walls, usually 
without, and not freely communicating with the endothelium-lined 
vessels; second, lymphatic vessels proper. These conduits do not 
connect with blood-vessels. 

The juice-spaces, or lymph-spaces, separate the epithelial bodies 
which make up the stratum mucosiun of the epidermis, and they 
also extend between the protoplasmic threads, or prickles, that unite 
them. Such conduits may be regarded either as delicate excavations 
in the cement-substance between the epithelia, or as irregular channels 
in a soft, viscid, albuminoid, and readily coagulable substance between 
the protoplasmic threads. At times this intercellular substance seems 
capable of obstructing the conduits by which it is tunnelled, These 
juice-spaces exist in the papillse of the corium, and encircle the several 

'A 



34 ANATOMY AND PHYSIOLOGY OF THE SKIN 

glands, hair-follicles, and nail-beds of the skin. They also sheathe 
the connective-tissue fibrillar of the corium and surround the fat- 
cells. According to Darier, the donna is a "true lymphatic sponge." 

The lymphatic vessels arc relatively few, but they form a con- 
tinuous meshwork, with transversely and vertically disposed branches 
supplying all parts of the skin below the epidermis. The juice-spaces 
communicate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As these vessels 
pass to the deeper portions of the corium and below it they increase 
in size. The current of the lymph flows from the papillary apices to 
;ill parts of the pete, like the currents in the delta of a river, a reflux 
occurring at the lower limit of the interpapillary depressions of the 
pete downward, possibly through the sweat-pores which traverse 
the epidermis at these points. Thence the current flows freely down- 
ward to the lymphatic vessels in the corium, but the stream from 
the juice-spaces about the coil-glands and fat-tissue is retarded by 
reason of a more restricted communication with the lymphatic vessels 
below. In consequence of the retardation due to this anatomical 
peculiarity the formation of fat by filtration is facilitated. 

Muscles. Striated Muscular Fibers extend from the subcutaneous 
tissue into the derma; in the case of man they are found chiefly upon 
the face and neck, where they arc the analogues of more powerful 
skin-moving muscles possessed l»\ several of the lower animals. Some, 
as those in the region of the face, serve to give expression to mental 
emotion by the production of facial movements. 

Non-Striated Muscular Fibers exist either as minute oblique fasciculi 
in connection with the glands and follicles of the skin; as annular 
bands, such as those which surround the nipple; or as radiating and 
more or les> parallel rods, such as antagonize the orbicularis in the 
eyelids. 

Arrectores (Erectores) PHorum. — These muscles are found usually 
in connection with the hair-follicles. They originate by minute 
multiple fasciculi from the papillary portion of the corium, and are 
inserted at several points into the outer layer of several adjacent 
hair-follicles, just above the plane of the apex of the hair-papillae. 
Their general direction is oblique, and their muscle-bundles are em- 
braced and traversed by elastic fibers, which form a dense network 
about them. Elastic threads also connect them intimately with the 
connective-tissue bundles of the corium, and serve as tendons at 
either extremity of each muscular fasciculus. 

The muscles, by virtue of their oblique direction and mode of 
attachment,* include in the angle subtended by their muscular fibers 
the sebaceous glands connected with the hair-follicles. It follows, 
therefore, that by their contraction they aid in the expulsion of the 
sebaceous secretion formed in the gland; but their intimate union 
with the elastic tissue, which is evenly and generally distributed 
throughout the framework of the corium, results in their discharge 



PIGMENT 35 

of ;i still more important function in connection with the regulation 
of the body-temperature; since by virtue of direct compression ex< rted 
upon the skin the Mood may be driven from the surface in a centrip- 
etal direction and its cooling in a great degree prevented, as in the 
well-known phenomena resulting in the production of the cutis 
anserina, or "goose-flesh." The reverse of this naturally follows 
when the muscles expand under the influence of external beat. The 
anatomical connections of the arrectores pilorum are such that their 
contraction serves to approximate several of the papilla' of the corimn, 
including the hair-papilla. Thus, by their contraction, the sebaceous 
secretion may he extruded, or, as is more particularly exhibited in the 
lower animals, such hairs as the bristles of the boar may be erected. 

Muscular membranes exist in the skin of the scrotum, over the 
penis, about the nipple, and elsewhere. They are simply layers of 
smooth muscular fibers, which suffice when contracting to move the 
portions of skin to which they are distributed. 

Pigment. — The hue of the living integument is due in part to the 
degree of vascularity and distention of the vessels in the corium, and 
in part also to pigmentation of the epidermis. The coloring matter 
of the skin in health is deposited chiefly in from one to four rows 
of cells in the lower stratum of the rete, the fine granules of pigment 
staining both the cell-body and the nucleus, the latter more vividly. 
The pigment of the skin depends for its hue upon a substance called 
melanin. Its office is obvious. It is designed to absorb rays of light, 
and thus to aid in the protection of the body from undue insolation. 

The degree of vascularity of the skin is responsible for most of the 
flesh-tints, but the colors seen in the various races of men are wholly 
related to the character and quantity of pigment found in the rete. 
Rarely, pigment-cells are found in the corium in a state of health. 
This pigment depends upon a distinct and uniform coloration of the 
epithelia, and also upon minute granules of melanin entangled in 
the reticulum of living matter in the same part. Extreme variation 
in the distribution of pigment is noticeable both in health and in 
disease, and in individuals and races, being at times related to climatic 
and similar influences. This fact is well illustrated by the wide range 
between the flaxen-haired, pink-eyed albino and the blackest speci- 
mens of the negro, each, with small exception, being of African descent. 

It has already been noted that in the colored races the pigment 
may stain the epithelial cells and their nuclei as high as the granular 
layer; and that to this layer only is due the characteristic color of 
the skin of the white races. Pigment is not normally found either in 
the horny layer of the skin or in the subepithelial tissues. 

The source of the pigment in the skin has been the subject of much 
study. Karg,' Kolliker,-' and Ehrmann 3 all support the view of the 
derivation of the pigment from the hemoglobin and its transference 

1 Aicliiv 1'. Aunt. u. Physi., 1888, p. 369. 
'-' Zeitsch. F. Wissensch. Zoolog., 1887, xlv. 
Vierteljahr., L886, \iii. 



36 ANATOMY AND PHYSIOLOGY OF THE SKIN 

to the basal layer of the epithelium by special cells (melanoblasts,. 
chromatophores). Ehrmann considers these pigment-bearing cells 
derivatives from the mesoderm and different from connective-tissue 
cells or leukocytes. Delepine, 1 Jooss, 2 and more recently Meirowsky, 8 

Ilelmich, 1 McDonagh, 8 Dyson," and Kreibich 7 consider that the 
pigment is independently produced in the epithelial cells. 

The experimental work carried on by these observers appears to 
prove conclusively that the epidermal pigment is formed in the 
individual epithelial cells, the formation beginning in the nucleus 
and spreading from this situation throughout the cell. It is further 
believed by some that independent pigment-cells may be produced in 
the corium. 

Hairs. The study of the anatomy of the hair-apparatus includes 
the structure of the hairs themselves and the follicles in which they 
are implanted. Hairs are distributed over the entire cutaneous sur- 
face 1 , except on the palms and solo, the dorsal surface of the distal 
phalanges of the hands and feci, and the skin of the penis. They 
occur in three classes: the fine, downy hairs, or lanugo, covering the 
face, the trunk, and the limbs; the long, soft hairs found on the 
seal]), over the pubes, and in the axilhe; and the short hairs, which 
include the soft varieties found on the brow and the still' hairs of the 
eyelids. The wide variation in color depends upon the amount of 
pigment grannies, the soluble coloring matter, and the air which 
they contain. Hairs, on cross-section, are round, oval, or more or 
less flattened. The portion of the hair included in the skin is termed 
the hair-root, and its lowermost portion the hair-bulb. That 
portion extending from the surface to the free extremity is termed 
the shaft, and the terminal end the point. 

The bulb is a club-shaped expansion of the lower end of the hair, 
implanted upon and surrounding a nipple-like projection of the 
corium termed the hair-papilla, which resembles the vascular papilla 
of the papillary layer of the corium. When uncut and normal, the 
external extremity of the hair ends in a sharp point. 

The distribution of the hair is determined by the fibrous tissue 
of the corium, and corresponds closely with the lines of cleavage of 
the skin. In certain areas, such as the vertex of the scalp, the hairs 
are arranged in a circular manner, forming whorls. 

On cross-section the hair presents a cuticle, a cortex, and a medulla, 
and is composed of epithelial cells. 

Cuticle. — The external layer of cells of the hair is termed the cuticle. 
This is composed of cells quadrilateral in shape, flat and regularly 

1 Proceedings of Physiological Society, 1890, vi, p. 23; quoted by MacLeod, Histo- 
pathologic p, 306. 

2 Munch, med. Abhandl., I, Heft, xvi; quoted by MacLeod, Histopathology, p. 306. 

3 Monatshefte, August 15, 1906, p. 155; abstr. Jour. Cut. Dis., 1907, xxv, p. 192. 

4 Monatshefte, Bd. xlv, No. 4, 1907, August 15, p. 184; abstr. Brit. Jour. Derm., 
1908, xx, p. 169. 

s Brit. Jour. Derm., 1910, xxii, p. 316. 

6 Ibid., 1911, xxiii, p. 205 

7 Archiv, cxviii, No. 3; abstr. Brit. Jour. Derm., 1914, xxvi, p. 171. 



CORTEX 



37 



overlaid, resembling the tiles on the root' of 8 house. They have 
their long axes directed upward and outward al an acute angle with 
the shaft. 

Fig. 11 J to. 12 




Section of a hair-follicle during; the 
formation of a new hair: a, external and 
middle root-sheaths; l>, vitreous mem- 
brane; c, papilla with vascular loop; 
'/, externa] root-sheath; e, internal root- 
sheath; /.cuticle of hair-follicle ; g, cuticle 
Of hair; h , /, young hair; /. bull) of old 
hair; fc, debris of external root-sheath of 

hairrecently expelled. (After Ebner.) 







% 







Hair-follicle in Longitudinal section: 

a, mouth of follicle; h, neck; c, bulb; 
d, e, dermic coat; /, outer root-sheath; 
g, inner root-sheath ; h, hair; fc, its medulla; 
/, hair-knob; m, adipose tissue; n. hair- 
muscle; 0, papilla of skin; />, papilla of hair; 
S, rete mUCOSUm, continuous with outer 

root-sheath; ep t horny layer; /, Bebaceous 
gland. 



Cortex. In its upper portion, the hair consists entirely of the 

cortex. Lower down a medulla is present. The et'lls of the cortex 
are spindle-shaped and have a fusiform nucleus. They contain eolor- 



:;s 



ANATOMY AND PHYSIOLOGY OF Till-: SKIN 



ing matter, and between them are found pigment-granules and air- 
spaces. The strength, elasticity, and extensibility of the hair are due 
to the arrangement of the cells of the cortex. 

Medulla. — The medulla occupies the centre of the hair and extends 
a variable distance up the shaft. In its upper portion, it consists of 
several rows of flattened epithelial cells, which near the bulb become 
cubical in shape and contain keratohyalin. In the lanugo hairs the 
medulla is absent. 

Fig. 13 







Lower portion of hair-pouch from the lip of a kitten: F, follicle; T, transverse section 
of connective-tissue bundles of derma; M, arrector pili muscle; IS, inner root-sheath; 
OS, outer root-sheath; P, papilla; C, cuticle; R, root of hair; H, hyaline, or so-called 
"structureless," membrane. Magnified 500 diameters. (After Heitzmann.) 



Hair-Follicle. — The hairs are implanted in the skin in a series of 
invaginations called hair-follicles. Usually, only one hair springs 
from a single follicle, but occasionally there may be two or more. 
The hair-follicle is an elongated, cylindrical pouch, dipping down into 
the corium, and at times into the subcutaneous tissue. Its upper 



/, \ VERS AL hoot sill: \ I II 



;•) 



portion, termed the mouth, is funnel-shape 
the cutaneous surface. The neck of the fol 

lion, and is situated at the junction of the 



Fig. 14 



I and open directly upon 
'licle is it - narrow <■ I por- 

middle and upper t hird . 
and at this point occur the orifices of the sebaceous glands. Below 
this the pouch gradually enlarges to cud in a bulbous extremity, which 

contains the hair-hull) and hair-papilla. The follicle has a fibrous 
portion derived from the corium, and an epithelial portion made up 
of the various layers of the epidermis. The fibrous coat of the hair- 
follicle is divided into three layers: an external, thin, dense layer of 
connective-tissue fibers and cells, arranged in a longitudinal direc- 
tion; a middle, thicker layer, with a circular arrangement of the 
fibers and bundles; and an internal, condensed layer, presenting a 
homogeneous appearance. This last-mentioned layer is commonly 
described as the hyalin layer, or vitreous layer, and is present 
chiefly in the lower part of the follicle. The epithelial portion of the 
hair-follicle is composed of the various layers of the epidermis. The 
layer next the hair, corresponding to the 
stratum corneum, is termed the cuticle. Ex- 
ternal to this is a complicated structure 
termed the internal root-sheath; and out- 
side of this is the external root-sheath, 
which is virtually a continuation of the 
prickle-cell layer of the epidermis. 

Cuticle. — The cuticle is composed of a 
single layer of elongated cells, with their 
long axes arranged downward and inward. 
By recalling the arrangement of the cells 
of the cuticle of the hair, it will be seen 
that by the special arrangement of the cells 
of the two cuticles they interlock and thus 
make a firm union between the hair and 
its follicle. This anatomical arrangement 
accounts for the removal of a part of the 
root-sheath when a hair is epilated. 

Internal Root-Sheath. — The internal root-sheath occupies the lower 
two-thirds of the hair-follicle. The inner part of this sheath is known 
as the "sheath of Huxley/' while its outer portion is termed the 
"sheath of Henle." The cells of the inner portion (sheath of Huxley) 
arc nucleated and contain granules of keratohyalin. Those of the 
outer portion (sheath of Henle) are smaller, have lost their nuclei, 
and have become cornified. There are spaces between these cells 
through which processes from the cells of the inner layer extend, on 
account of which this layer has been described as a fenestrated 
membrane. In the upper part of the follicle, these two layers lose 
their identity through the cornification of the cells of the inner layer. 

External Root-Sheath. This is represented by a continuation of the 
Stratum mucosum downward into tin 4 follicle. The stratum corneum 
and the stratum granulosuni accompany the stratum niucosiun down- 




Transverse section of hair and 
follicle. 



40 ANATOMY AND PHYSIOLOGY OF THE SKIN 

ward as far as the opening of the sebaceous gland at the neck of the 
follicle. From here downward to near the papilla the stratum muco- 
suni consists of several layers of polyhedral epithelial cells, while near 
the base of the papilla it is reduced to a single layer of ceils. 

Hair-Change. — During life, the hairs are being constantly shed and 
replaced by new one-. In the scalp, they are said to have an existence 
of from two to four years, when they are replaced by new ones. In 
addition to the intermittent falling of the hairs, there are certain 
period- during which great changes occur. Immediately after birth, 
the hairs grow actively on the scalp. At puberty, hairs appear in 
certain regions, such as the beard, the axilhe, and about the genitalia. 
In middle life and later year-, hairs grow in and about the ears and 
nostrils. In female-, after the menopause, there is frequently an 
increase of hairs on the face. All these hairs (called "periodic hairs" 
by MacLeod i are pigmented and coarse, while those of the rot of 
the body retain their unpigniented condition. 

Nails. Nails arc compact, -olid plates of highly cornilied epithelial 
cells, situated on the dorsal surface of the distal phalanges of the 
fingers and toes. They are convex from side to side, also from before 
backward, but to a less degree. Three edges of the plate are inserted 
into the skin, one, the anterior, being free. The posterior edge is 
slightly concave, the lateral edges straight and parallel, and the 
anterior edge convex. The visible portion of the nail-plate is termed 
the body, the posterior one-fifth of which i- occupied by a semilunar, 
whitish portion, termed the hinidc. The portion of the nail-plate 
embedded posteriorly is called the root. The three edges of the nail- 
plate rest in a depression termed the nail-groove; and the skin ex- 
tending from this over the nail for a short distance laterally, but further 
posteriorly, i> called the nail-fold or nail-wall. The thin, crescentic 
membrane extending from the posterior wall a short distance over 
the lunule represents the remains of the eponychium. The hypony- 
chium is that portion of the epidermis upon which the nail-body rests, 
and the perionychium is that portion of the epidermis surrounding 
the entire nail-border. 

The following structures are presented for microscopic study: the 
nail-fold, nail-matrix, nail-bed, and nail-plate. 

Nail-Fold. — The nail-fold is divided into an upper and a lower 
portion by the nail-root. The upper portion, extending backward, 
consists of the various layers of the epidermis forming a roof for 
the nail-root. The stratum corneum lies upon the nail-root, and the 
finger-like projections of the rete are obliterated and represented here 
by a straight line. The lower portion, extending forward beneath 
the nail-root, represents the nail-matrix. 

Nail-Matrix. — The nail-matrix corresponds to the lower portion of 
the nail-fold, and extends forward to the anterior margin of the 
lunule. It is composed of a prickle-cell layer continuous with the 
same layer behind forming the roof of the nail-fold, and in front with 
the prickle-cell layer of the nail-bed. The prickle cells in this situa- 



v ML PLATE 



II 



tion are larger than those of the same layer anteriorly and po teriorlj 
[nterpapillary ridges are presenl and are more marked posteriorly. 
The matrix is composed of layers of cells analogous to those of the 
epidermis, with some variation noted, as follows: A basal layer, 
composed of regular, cylindrical epithelial cells. Immediately above 
this are from three to ten rows of cells of polygonal shape, and above 
this several rows of flat, closely-packed cells, having shriveled nuclei 
and containing fine granules. Above this are found the horny com- 
plete nail-cells. The nature of the granules mentioned in the tran- 
sitional layer is not settled. Ranvier (quoted from MacLeod; terms 
them onychogene. Okamura 1 regards them as keratin granules^within 
the cells. A third hypothesis is that they are shrunken prickles 
"seen in relief" (MacLeod). 

Fig. 15 

b c d 







~'±&*''>-^~j&- > '': 




Vertical section of one-half of nail and matrix: a, nail-substance; b, horny layer; 
c, mucous layer; d, papillae of corium; e, nail-furrow destitute of papilla?;/, horny layer 
of the ungual furrow rising above the nail; g, papillae of skin of dorsal surface of the 
finger. 

Nail-Bed. — The nail-bed extends forward from the matrix to the 
horny layer of the pulp which joins the nail at its free edge. The 
nail-plate rests upon the nail-bed. The nail-bed has a basal layer of 
cells presenting longitudinal edges, several layers of polygonal cells, 
and above these flattened cells, upon which the nail-plate rests. 

Nail-Plate. — The nail-plate {true nail) is produced entirely from 
the matrix and is pushed forward over the nail-bed. The upper 
cells spring from the posterior portion of the matrix, while those 
beneath are produced by the anterior portion. It is suggested that 
the pressure exerted by the roof of the nail-fold helps to direct the 
growth forward in place of upward. The nail-plate is made up of 
flattened epithelial cells arranged in lamellae, and each cell contains 
the remains of a nucleus. This cellular structure is best seen near 
the matrix; the cells further forward being so closely associated as 
to become an almost homogeneous mass. The under surface of the 
nail-plate is traversed by fine longitudinal ridges, which fit into cor- 
responding depressions in the nail-bed. 



Archiv, L900, lii. p. 223; quoted from MacLeod. 



42 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



The process of cornification occurring in the nail is apparently 
accomplished without the interposition of keratohyalin and eleidin, 
and the final product differs from keratin in the degree of hardness 
and otherwise. Finally, the presence of shrunken nuclei in the 
eornified cell is different from the usual process of cornification de- 
scribed in the epidermis. The structure of the eorium and subcutaneous 
tissue of the nail region presents certain peculiarities. Collagen- 
bundles radiate vertically from the periosteum of the phalanx to the 
epidermis of the nail-bed, closely binding these structures. Other 
collagenous bundles are present having a horizontal arrangement. 
Elastic i- present below the matrix, and to a less degree beneath the 
nail-bed. Blood-vessels and lymphatics are present in this meshwork, 
and also a moderate amount of fat (MacLeod). The papillary body 



Fig. L6 




-_' * y. ■ 



Implantation of a nail at its holder: P. papillae decreasing in size toward the mid- 
dle line; R, rete mucosum, which broadens toward the horder of the nail, and forms 
irregular prolongations; R' , E. epidermal layer; X, plate of the nail. Magnified 500 
diameters. (After Heitzmann.) 

has a special arrangement, described by Hans v. Hebra 1 (quoted 
from MacLeod). Beneath the matrix posteriorly occur from three 
to six rows of small, isolated papilla?. Anterior to this is seen a series 
of ridges, which are curved at the sides, but parallel with the long 
axis of the nail in the centre. On the edges of these ridges, rows of 
papilla? are present, giving this region the appearance of a cock's- 
comb. From here forward to the anterior part of the lunule the 
ridges flatten and papillae are absent. The papilla? of the nail-bed 
are arranged on a large number of ridges running parallel with the 
long axis of the nail, and anterior to this the ordinary papilla? of the 



Wiener mcd. Jahrb. 1880, p. 59. 



GL Whs 



13 



corium of finger-pulp occur. A copious supply of blood-.' el i 
found in the papillae and ridges above described. Beneath thi.^ is 
a rich j)lc\us of bloodvessels, on which various sinuses lined with 

endothelium arc present. Into these sinuses the capillaries of the 
papillae empty their contents. 

The growth of the nail is continuous during the life of the individual, 
being more active in the young and during the summer season. From 

l()(i to 1(H) days are required for the reproduction of a finger-nail 
and about three times that period for a nail of the toe. 

Fig. 17 






Fig. 18 




Sebaceous glands of the second class, from the alae of the nose. (After Sappey.) 



Glands. -Sebaceous glands, or sebiparous glands, are pyriform 

bodies, usually racemose in development, situated in the corium. 
They furnish a more or less consistent and fatty secretion, destined 
to anoint the skin and the hairs. They are divided into three classes. 
The first class includes the sebaceous glands that are appendages 
of the hairs and hair-follicles. They an 1 developed early in fetal 
life from minute, lateral, hud-like prolongations from the outer root- 
sheath of the hair. From two to six of these prolongations spring 



44 



ANATOMY AND PHYSIOLOGY OF THE SKIN 



from tin* prickle-layer of the hair-follicle, and the prickle-cells in the 
axis of each hud speedily undergo fatty metamorphosis. In the 
mature gland, each acinus is formed of a membrana propria supporting 
layers of nucleated cuhoidal epithelial cells furnishing- fat. Gradually 
the fatty cells are pushed outward toward the duct of the gland, 
where, sooner or later, their rupture releases the drops of fat (sebum) 
just where the hair emerges from the closely applied follicle below to 
the funnel-shaped mouth of the hair-pouch above. Externally, each 
gland is provided with a layer of connective tissue provided with 
blood- and lymph-vessels and uerves. Sebaceous follicles are found 
in connection with the long, soft hairs, as those of the scalp and axillae, 
several being grouped around a single hair-sac. 



Fig. 10 




Coil of a sweat-gland: S, tubule lined with cuboidal epithelia; T, central caliber 
of the tubule; J), beginning of the duct; C, connective tissue with injected blood-vessels. 
Magnified 500 diameters. (After Heitzmann.) 



The second class includes the large and complex glandular structures 
to which the lanugo hairs seem accessory, the orifices of their re- 
spective ducts opening directly upon the cutaneous surface. 

The third class includes those sebaceous glands opening directly 
upon the surface and unconnected with hairs or hair-follicles. Such 
are the glandular odoriferse of the male and female genitalia, and those 
existing about the lips and in the areola of the nipple. These glands 
might be designated as "glands of the mucous orifices" (Unna). 

Meibomian and Tysonian Glands. — These are of the largest order 
of sebaceous glands. The former exist within the free border of the 
eyelids; the latter upon the glans penis and the inner surface of 
the prepuce. They are unconnected with hairs, and differ in this 
respect from other types of sebaceous glands. 



COIL GL I VDS 15 

Glandulae Ceruminosie. These are situated in the subcutaneous 
tissue of the meatus of the ear, and product' the waxy secretions found 
in this situation. The "glands of Moll" found in the eyelid are to 
Declassed with the sweat-glands. 

Coil-Glands. Coil-glands (sweat or sudoriparous (//and*-, glandulce 
glomiformes) are found within the skin of all regions of the body, 
being exceptionally numerous in the palms and soles. They arc situated 
in the subcutaneous tissue, as a rule, with an occasional one in the 
deeper part of the corium. In certain regions, such as the axillae, the 
groins, the palms, the soles, and about the anus, the coil-glands are 
multiple and of unusual size, and often of peculiar arrangement. For 
descriptive purposes, the coil-gland apparatus is divided into the 
gland (the coil proper), the sweat-duet, and the sweat-pore. 




>> l^afc^v- ^^ 



y^^'-v 



eZ-PL 




Sweat-pore traversing the epithelial layers of the skin: BP, papilla with injected blood- 
l', valley between two papillae; D, duet in the rete mucosum; E, E, epidermal 
layer; PL, coarsely granular epithelia, deeply stained with carmine; P, duct with coik- 
Bcrew windings in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) 

Coil. — The coil is simply the end of a tube coiled upon itself from 
a few to several times. The tube terminates in a cecal pouch and is 
lined with a single layer of nucleated cuboid epithelial cells, having 
a granular appearance. Outside of the tube are smooth, muscular 
fibers, running parallel with or in a spiral direction about the coil. 
Surrounding both muscle-bundles and epithelium, a connective- 
tissue membrane is described. The glomerulus or coil is globular 
in outline and reddish-yellow in color. In the larger glands, irregular 
dilatations and constrictions of the tube are conspicuous. 

Coil- Duct. The excretory duct of the coil-gland passes from the 
glomerulus below to the epidermis above in a straight or a spiral 
Course. It is lined with delicate hyalin cuticle (Ileynold), beneath 
which is a double layer of cuboidal epithelial cells. Externally is 



40 



AX ATOMY AX J) 1'UYSIOLOGY OF THE SKIN 



a membrana propria, unprovided with muscular fibers. The external 
sheath consists of connective tissue. At the border line of the epider- 



Fig. 21 





Section of the skin from the palm of the hand (hardened in Moeller's fluid and treated 
with glacial acetic acid), magnified 300 diameters, showing epidermis and pars papillaris 
of the corium traversed by the excretory duct of a coil-gland terminating in a sweat- 
pore: a, stratum corneum; a', its superficial layer, the cells in the upper and lower layers 
somewhat larger than those situated between the two; b, stratum lucidum; c, stratum 
granulosum; d, stratum mucosum; e, rete-pegs; /, interpapillary process of rete meeting 
duct of coil-gland; g, g, papillae embraced by long prickles extending from lower palisade- 
layer of the rete; h, blood-vessels of papillae; i, bundles of connective-tissue fibers of pars 
papillaris; k, section of spiral duct of coil-gland and sweat-pore. 



DEVELOPMEh T OF THE s/</.\ l< 

mis, the cuticle and external connective-tissue sheath afe lost, and 
the <luct here becomes a sweat-pore. It occasionally opens within 
a hair-pouch. 
Sweat-Pore. This is ;i continuation of the excretory duct of the 

coil-gland alter the loss of its cuticle and connect ive-tissue sheath. 
The sweat-pore traverses the epidermis usually in a spiral direction, 
and terminates in a funnel-shaped opening through the stratum 

corneum. It is a wall-less channel, and therefore in free communication 
with the juice-spaces of the epidermis. This anatomical peculiarity 
provides fully for the needs of evaporation at the surface of the body. 
The alternation of muscular fibers with the secretory cells of the 
ducts of the coil-elands is a provision for the extrusion of the gland 
secretion onward. The same anatomical arrangement permits com- 
munication between the epithelial cells and the lymph-spaces which 
reach into the connective-tissue sheath of the gland. As a result, 
the lymph flows freely among the secreting elements of the gland and 
its duct. This lymph, loaded with fat, streams away from the coils, 
and before it reaches the lymphatic trunks its fat-globules are filtered 
away in the subcutaneous tissue. The total number of coil-glands 
in the body is estimated to be between 2,000,000 and 3,000,000, and 
the total length of the uncoiled glands to be eight miles. These 
figures serve to give an approximate idea of their very great physiolog- 
ical importance and of the extent to which violation of the rules of 
h,\ giene possesses interest from a pathological view-point. 

DEVELOPMENT OF THE SKIN. 

From an embryological standpoint, the skin is composed of two 
layers, the epidermis and corium; the epidermis developing from the 
epiblastic layers, and the corium from the mesoblastic layers, of the 
blastodermic vesicle. The corium and subcutaneous tissue are now 
regarded as layers of a mesoblastic structure maturing from within 
outward, increasing by cell-division and by the formation of fibrous 
bundles and the deposition of fat in the deeper layers. 

The epidermis early in the blastodermic vesicle consists of a layer 
of polygonal nucleated cells, termed " Hauber's layer, " beneath which 
is a layer of cubical cells with large, round nuclei. Between the first 
and second months of fetal life three layers are distinguished most 
superficially: Rauber's layer, the cells of which have become Hat; 
and two layers of columnar cells. About the third month, the " bladder 
cells" of Zander become demonstrable in the regions of the tips of 
the fingers and toes. These latter appear to be certain cells of Kauber's 
layer which have become swollen and dome-shaped (Bowen). 

Epitrichial Layer. -Welcker, Minor, and Bowen 1 have described 
a layer of large cells, with round nuclei much larger than those of 
the epidermal layers beneath, covering the entire body of the human 

1 Jour. ("lit. Dis., L895, xiii, p. 185. 



48 ANATOMY AND PHYSIOLOGY OF THE SKIN 

embryo during the early months of its existence. This layer, histologi- 
cally, is quite distinct from the outer cells of the stratum corneum, 
and corresponds with the epitrichium of certain animals. It usually 
disappears before the sixth or seventh month of intra-uterine life. 

At the end of the fourth month, the epidermis consists of five or 
six rows of cells: a superficial row of flattened cells, beneath which 
are several rows of cells of polygonal shape. In the lowermost layer, 
mitotic figures may be demonstrated. By the sixth month, marked 
proliferation has taken place in the epidermis, and the epitrichium 
has disappeared except in the fingers and toes and over the developing 
nails. By this time, also, the proliferating epidermis has formed the 
papillae, and a short time later (about the seventh month) the prickle- 
cells take on their peculiar characteristics. Keratohyalin granules 
become evident about the eighth month, and keratin is also present 
in the cells of the stratum corneum. 

Coil-Glands. The firsl evidence of the coil-glands may be found 
in the palms and soles, between the fifth and sixth months, as a conical 
down-growth of the epidermis. Very shortly afterward, these gland 
rudiments spread oxer the entire subcutaneous surface, except that 
part occupied by hairs. The rudiment gradually pushes downward 
into the corium and becomes constricted near the upper part, forming 
a neck, and widens out beneath into a globe-shaped thickening. 
These down-shoots occur over the mterpapillary processes of the epider- 
mis, and the cells are those composing the epidermis from which it 
sprang. Between the sixth and seventh months, the central cells 
of the developing gland break down and the beginning of a canal 
becomes appreciable. When this rudiment reaches a certain position 
in the corium, the end turns and the subsequent growth produces a 
coil. 

Sweat-Pores. — The sweat-pores are first demonstrable between 
the seventh and eighth months, some time after the gland is fully 
developed. Fat-globules may be seen in and between the cells of the 
coil before there is any external outlet. The fat appears to pass out 
from the cells of the coil to the surrounding tissue. As no sebaceous 
glands are present on the palms and soles, it has been suggested that 
the vernix caseosa has been produced by coil-glands. 

Hairs. — The first change noticeable in the area which is to form a 
lanugo hair is a down-growth of the epithelium into the corium, 
occurring between the second and third months of fetal life, and 
situated about the forehead and eyebrows. From here these down- 
growths spread to all regions of the body, except the palms and soles. 
Between the fourth and fifth months, the hair itself begins to form in 
this early rudiment. By the sixth month, a lateral outgrowth from 
the hair-rudiment has developed into a sebaceous gland. Immediately 
beneath this is a small projection for the attachment of the fibers of the 
arrectores pilorum. When the hair becomes sufficiently rigid, it pierces 
the horny layer of the epidermis and makes its appearance on the 
surface. At about the seventh or eighth month, the lanugo hairs 



PHYSIOLOGY OF rill'; SKIN 19 

begin to exfoliate and are replaced by new hairs growing out of the 
old follicles. This change is sometimes completed after birth. A 
very clear conception of the development of the hair as it occur in 
the rabbil is quoted from MacLeod: 

"A solid process of epithelial cells grows down from the epidermis 
into the underlying connective tissue of the corium; a small, vascular 
papilla of connective tissue forms below the down-growing process; 
the papilla increases in size, indents the fundus of the process, and 
from it a sheath of connective tissue spreads up to envelop the process 
and forma follicle; the axial cells of the process then become cornified 
and a hair is formed; the hair grows and finally breaks through the 
overlying epidermis, and the development is complete." 

Sebaceous Glands. — The sebaceous glands appear first about the 
fifth month of fetal life as merely knob-like outgrowths of the hair 
rudiments, and are composed of cells of the same type. As they grow, 
they become pear-shaped, and have their long axes directed obliquely 
downward. The original process buds to form a number of saccules 
enclosed in a connective-tissue sheath continuous with that of the 
hair-follicle. From two to six glands develop in connection with each 
follicle. 

PHYSIOLOGY OF THE SKIN. 1 

The skin, through its various component parts, renders great 
service to the body as a whole through performing many physiolog- 
ical functions vital to life. Most important of these are protection, 
heat regulation, secretion, sensation, and respiration, the last-named 
only to a small degree. The skin is not simply an inert envelope in 
which the structures of the body are confined, but is a living organ 
comparable in importance to the liver, kidneys, and other similar 
organs. 

Protection. — The epidermis is a poor conductor of electricity and 
light. In the tropics, where the light is greatest, the natives are 
provided with an increased amount of epidermal pigment to screen 
them from the light. Inhabitants of the temperate zone, while visit- 
ing tropical countries, require such clothing and shelter as will assist 
the epidermis in checking light-penetration. 

The fatty matter in the stratum corneum prevents evaporation of 
the fluids of the body. The impermeability of the stratum corneum 
protects other organs of the body from the absorption of water and 
other fluids. Keratin is a substance which enjoys great power of 
resistance to chemicals of all kinds. Resistance to microorganisms 
which are normally present in the epidermis and to those also that 
are pathogenic that find accidental lodgment in the skin is provided 
by the impenetrability of the granular scales, their coherence, and 
the fatty matter present. The points offering least resistance to 

1 In the preparation of this chapter the following works were consulted: La Pratique 
Dermatologique, Tonic I , Tigerstedt's Physiology, 1905; Duhring's Cutaneous Medicine, 

IS'. Hi. vol. i. 

I 



50 ANATOMY AND PHYSIOLOGY OF THE SKIN 

their entrance are the glandular orifices. In sweat-glands there may 
be an acid secretion (the sweat) exuding from a narrow, tortuous 
canal. The weakest point in the epidermis is the pilo-sebaceous 
system, where the sebaceous secretion, which is pasty and fatty, offers 
sod ■ resistance. The fibrous corinm, by its strength and elasticity, 
with the loose, fat-containing subcutaneous tissue, acts as an ideal 
support and protective apparatus against external injury of the 
delicate nerves, with their special endings, the blood- and lymph- 
vessels, the glands and hair-follicles of these regions. The brain has 
an extra protection through the abundant hair-growth of the scalp. 

Heat-Regulation. In health, the temperature of the blood is 
maintained at nearly a given point, though the body be exposed to 
temperature changes of wide variation. This j s accomplished, in 
the main, by the skin through radiation, conduction, and evaporation. 
When the body is overheated, either from external or internal causes, 
the blood is determined to the surface capillaries, with loss of heat 
by conduction and radiation; and at the same time increased activity 
of the coil-glands is stimulated, with outpouring of sweat, which by 
evaporation dissipates such heat. When the body is exposed to the 
cold, the cutaneous capillaries contract, sweat-secretion is diminished 
or stopped, and loss of heat is thus prevented. In addition, heat loss 
is lessened through contraction of the arrectores pilonmi, which 
occurs when the body is chilled, by lessening the exposed cutaneous 
surface. The vasomotor system regulating the blood supply is inti- 
mately concerned in the phenomena above described, and apparently 
may act by direct excitation from without (heat and cold), or reflexly 
from within by fever, hot drinks, shock, drugs, etc. 

Secretion. — The secretory function of the skin is carried on chiefly 
by the sebaceous and coil-glands. Their office is to furnish oil and 
moisture to render the skin soft and pliable, and, to a small degree, 
give off waste material. They play an important part in the tem- 
perature. The sebaceous glands secrete in health greasy and oily 
matter (sebum), which anoints the greater part of the cutaneous 
surface, including the hairs. The palms and soles are not anointed 
by this secretion, and they are the only parts which show the effect 
of water even after prolonged immersion. In the glands, sebum is 
a fluid or semifluid substance, which may be of firmer consistency in 
the ducts, and is, according to Starling, rather a wax than a true fat, 
and composed of fatty acids united with the stronger alcohols, in- 
cluding cholesterol. The expulsion of sebum from the glands to the 
surface is accomplished largely by contraction of the arrectores pilorum 
muscles which surround the sebaceous glands. 

Sweat is composed largely (98 to 99 per cent.) of water. It is color- 
less, and has a specific gravity of 1003 to 100S. Its reaction may be 
acid, alkaline or neutral. It has an unpleasant odor and a salty taste. 
The odor varies according to the part of the body from which it is 
secreted. L 'trier ordinary conditions it is acid, but after profuse per- 
spiration its reaction becomes neutral or alkaline. The chemical 



PHYSIOLOGY OF THE SKIN 51 

composition of sweal is difficult to ascertain, owing to the admixture 
wit 1 1 materia] from the sebaceous glands, which necessarily cannot 
be eliminated. The quantity daily excreted is variable and depends 
largely upon the requirements lor heat-regulation. The ; •> it 
in twenty-four hours is probably between a pint and a half ant .wo 
pints. Urea is ordinarily present in very minute quantity, but in 
certain pathological conditions, such as uremia, may become appre- 
ciable in amount. While the entire skin secretes sweat, certain por- 
tions, such as the brow, face, neck, axillae, genital regions, palms, and 
soles, are the chief areas of such activity. That there is a division of 
work between the skin and the kidneys in excreting water is shown 
by the light color of the urine in winter, when perspiration is at a 
minimum, while the urine is heavy and darker in color in summer, 
when the skin is actively secreting. The sweat-secretion is influenced 
both by reflex and central stimulation. The secretion is increased by 
elevation of the external temperature, by copious warm draughts, by 
certain drugs, such {is pilocarpin, strychnia, camphor, ammonia, etc., 
and by such psychic phenomena as fright and anxiety. It is dimin- 
ished by external cold and such drugs as morphin and atropin, and 
in certain pathological conditions, such as diabetes. The nervous 
centres for its regulation are located both in the medulla and spinal 
cord. The sweat-centres may be stimulated by venous blood caused 
by dyspnea preceding death, and reflexly by exciting the mucous 
membranes of the mouth with mustard and other condiments (Halli- 
burton). While increased perspiration occurs as the result of vaso- 
motor dilatation of the vessels in the skin due to heat or muscular 
activity, it may occur independently of this, as is shown in the psychic 
causes mentioned. 

Absorption. — It is generally admitted that the intact skin is im- 
permeable to water and other solutions. Normal fats, on the other 
hand, are absorbed to a certain degree, as well as chemicals incor- 
porated in such fats. Advantage of this is taken in the treatment 
of syphilis by inunction. When the epidermis is removed, absorption 
may readily take place, and this fact should be borne in mind when 
making applications containing toxic agents to large inflammatory 
areas in which the stratum corneum has been removed. 

Sensation. — This function of the skin provides a means of pro- 
tection and discrimination. It was formerly thought that different 
sensations were awakened by various degrees and kinds of irritation 
applied to a single nerve-ending. Through the work of Blix (1833) 
and Goldschneider ( 1886), it is now known that there is a disassociation 
of sensation. There are different nerve-endings for heat, for cold, 
lor tactile sense, and for pain. 

Temperature- Sense. — There are scattered over the surface of the 
body certain points which convey only the sensation of cold, whether 
the irritation be electrical, mechanical, chemical, or by a hot or cold 
needle. There are other points which transmit only the sensation of 
heat. Where the tactile sense is most acute, as in the hand, the 



52 ANATOMY AND PHYSIOLOGY OF THE SKIN 

temperature sense is diminished. The topographical areas of heat 
and cold must be studied from charts. 

Tactile-Sense. — This sense is not equally distributed over the surface 
of the body. It is keenest in the finger-tip and the point of the tongue. 
It includes relative perception, with discriminations as to roughness, 
smoothness, hardness and softness, dryness and moistness. Relative 
perception is often an aid to vision. Pressure-sense is often increased 
by the presence of hairs. 

Pain-Sense. — Where the surface is denuded of epithelium, it is 
not apt to receive other sensation than that of pain. Pain, too, is 
experienced from thermal, mechanical, chemical, or electrical irrita- 
tion of severe character. There are nerve-terminals which receive 
no other impression than that of pain. 

The nature^ of sensations of itching, tingling, and creeping has not 
yet been fully determined. Clinical observation suggests that one 
of the* important factors in the production of itching is pressure on 
the epidermis. Any inflammatory or serous exudate occurring in 
just the right location to produce an outward pressure on the epider- 
mis will cause itching. 1 1' the exudate is more deeply located, other 
sensations are experienced. Tingling and creeping sensations are 
apt to denote deranged innervation. 

Respiration. The respiratory activity of the skin depends on its 
permeability to gases and vapors, in which function it is accessory 
to the lungs. The manner in which this is accomplished is through 
a diffusion between the circulating blood in the capillaries and the 
atmosphere. Physiologically, oxygen i> absorbed as well as some 
other gases. Water, carbon dioxid, and a trace of nitrogen are 
expelled. The respiratory function of the skin is not important and 
is far less in man than in amphibious animals (frog), whose skins are 
more like mucous membranes. The skin of these animals cannot be 
transplanted to man. 



II. GKXKRAL SYMPTOM A TOLOGY 



I\ cutaneous, as in other diseases, the clinical signs or symptoms 
of a morbid process are those by which a disease is recognized alike 
by the patient and the physician. These manifestations are divided 
into subjective and objective: The former are those appreciated by 
the patient alone, in consequence of his sensations; the latter are 
those detected by the eye and the touch of another who undertakes 
the investigation of the disease. There are manifested to the eye 
and touch of the patient many objective signs which are liable to be 
interpreted or misinterpreted by him, with consequences not to be 
ignored. Some diseases of the skin have associated general symp- 
toms, in which the cutaneous lesions are merely one expression of the 
pathological process. It is therefore necessary to study in detail not 
only those symptoms seen on the skin and described by the patient 
relative to the skin, but also to detect any departures from the normal 
in the condition of the viscera, and properly interpret these findings. 

SUBJECTIVE SYMPTOMS. 

The purely subjective symptoms of a disease of the skin are those 
manifested to the patient by sensations other than those connected 
with vision and his own sense of touch. They include sensations of 
itching, smarting, tickling, pricking, and burning; sensations as of 
increased or diminished susceptibility to the contact of foreign bodies; 
of increased or diminished temperature; pain in various grades of 
severity; and disordered sensations, such as those suggesting the 
crawling of insects over the part, the passing of currents of hot or 
cold vapors or liquids, and the compression of portions of the skin 
as by cords, bands, or closely fitting plates. The character of the 
subjective sensations experienced by a patient often proves an aid 
in recognizing the nature, not merely of a present disease, but also 
of one which has preceded. Thus, the sensation produced by an 
attack of erysipelas is rarely an itching, while the latter is highly 
characteristic of eczema and scabies; and the pain of zoster and 
the tingling of urticaria are distinctly different, not only from each 
other, but also from the' subjective symptoms named above. 

OBJECTIVE SYMPTOMS. 

The study of the objective symptoms of a cutaneous disease is 
of paramount importance. It is only through a clear understanding 

(53) 



54 GENERAL SYMPTOMATOLOGY 

of these features that a correct diagnosis of a cutaneous disease can 
be made. These symptoms are spread before the eye, and their 
legibility increases with every hour of careful observation. 

These signs of skin-disease are called "lesions" (efflorescences, 
elements of an eruption), and it is usual to classify them as primary 
and secondary (a number of which occur in each group). Such divi- 
sion, however, is open to criticism, since, in point of time merely, 
some of the so-called "primary lesions" of the skin become in turn 
secondary and even tertiary. Thus, a papule 4 which might at one time 
be called "primary" may be transformed wholly or in part into a 
vesicle, which thus becomes a secondary lesion; and such vesicle 
again, in. the evolution of a disease, may become a tertiary pustule, 
and the latter finally may result in a quaternary crust. In the fol- 
lowing pages these symptoms of skin-disease are distinguished as 
elementary or primary and consecutive or secondary. 

Elementary (or Primary) Lesions. In describing the average size 
of cutaneous lesions it is less convenient to state their measurements 
in fractions of a line or of a millimeter than to convey an approximate 
idea by comparison with familiar objects of relatively fixed dimen- 
sions. The objects usually -elected lor this purpose, beginning with 
the smallest, are seeds of the poppy, mustard, and rape; the coffee- 
bean; the pea; the bean; the cherry; the finger-nail; the chestnut; 
the horse-chestnut; the egg of the hen and of the goose; the orange. 
To these may also be added the point and head of a pin. 

Maculae. Macules (spots, stains; Fr., taches; Ger., Flecke) are 
generally circumscribed alterations in the color of the integument, 
differing in size, shape, hue, and duration of the dyschromia, and 
unaccompanied by elevation or depression of the skin-surface. 

Macules may be congenital or acquired; and may be the sole 
cutancou> symptoms present in any case or be commingled with 
others. They may be transitory or permanent, few or numerous; 
as minute as a pin-point or as extensive as the integument covering 
a limb. 

Macules may be due to arterial or venous hyperemia; to the escape 
of the coloring-matter of the blood into the skin; to acquired and 
congenital telangiectasis; and to pigment-anomalies. Examples of 
macules are to be found in the exanthematous rashes (measles); in 
localized hyperemia of the capillary plexuses of the corium, disap- 
pearing in various degrees according to the pressure exerted on the 
part (rosacea) ; in visible acquired development of blood-vessels in 
the skin (telangiectasis) ; in congenital vascularization of the surface 
(nevi) ; in variously colored blood-extravasations and stases (purpura) ; 
in stains produced by contact with dyes (hand-workers in anilin); 
and in pigmentary changes, such as those produced by solar heat 
(freckles) or by leprosy. 

Extensive non-circumscribed changes in the skin-color are seen in 
the course of several general disturbances of the economy, as in yellow 
fever, cancer, chlorosis, albinism, Addison's disease, argyria, and icterus. 



OBJECTIVE SYMPTOMS 55 

Spots of various color ;in<l device are also produced by the inten- 
tional or accidental introduction of pigmented particles beneath the 
epidermis, ;i> l>y the process of tattooing or the explosion of gun- 
powder. 

Maculae exhibit a wide variation in color, From a rosy-pink to a 
chocolate-brown or even a black. This difference has suggested the 
employment of such descriptive terms as roseola, erythema, and pur- 
pura, which, unfortunately, serve to distinguish both the features of 
diseases and the diseases themselves. 

A macule which encircles another lesion, as, for example, the halo 
around a vaccine vesicle, is called an areola. Linear hemorrhagic 
streaks are called vibices; punctate and larger extravasations of 
blood are termed petechia and ecchymoses. 

Maculo-papules are elevated spots which approach the type of the 
papule. 

Papulae. — Papules (Fr., papules; (Jer., Knotchen) are solid or com- 
pressible, ephemeral or persistent, circumscribed projections from the 
surface of the skin, varying in size from that of a poppy-seed to that 
of a coffee-bean. 

These exceedingly common skin-symptoms vary greatly in their 
shape, color, location, career, and significance. Thus, they may be 
flattened at the apex, acuminate or pointed, conical, rounded, or 
depressed at the summit to form an umbilication; they may be pale, 
rosy, dark or lurid red, purplish, or even blackish; they may develop 
in transitory or persistent processes; they may be transformed into 
lesions containing fluids; may desiccate and furnish scales either 
at apex or base; may degenerate into ulcers; or may enlarge into 
tubercles or tumors; may be scratched, torn, or rubbed so as to lose 
their typical appearance; may come and go; may be sensitive to 
sudden changes in the blood-current, and yet be persistent. 

The mixed forms described above are generally named vesico- 
papular or papulo-vesicular, papulosquamous and papulo^pustular 
lesions. 

Lesions which simulate the papule, and which, though described 
under that title, really belong to another category, are the small, 
semisolid elevations of the surface that form at the orifices of the 
ducts of the cutaneous glands and follicles. Thus, they may consist 
of little heaps of epidermis about the hair-follicles (lichen pilaris, 
keratosis pilaris), or of inspissated sebum collected in one or in all 
of the acini of the sebaceous glands (comedo). 

The concomitants of an eruption of papular type also vary. Thus, 
there may be a febrile process, or extensive infiltration of the skin 
about and beneath the papules (prurigo), or itching of the most in- 
tolerable character (eczema papulosum), or production of trifling 
sensations of annoyance, as a slight burning without other subjective 
s\ inptoins (acne). 

Papules transformed into moist Lesions become covered with a 
crust. Papules scratched or torn by the finger-nails usually betray 



56 GENERAL SYMPTOMATOLOGY 

the fact in the minute and fiat blood-crusts dried upon their surface. 
Papules which ulcerate may be followed by sears, and those which 
have undergone the process of involution may be followed by macular 
sequela 3 . 

Pomphi. — Wheals (urtwoe; Ger., Quaddeln; Fr., plaques ortiies) 
are more or less transitory, pinkish, rosy-red and whitish, irregularly 
shaped and sized elevations of the surface of the skin, produced by 
blood-stasis in spasm of the vessels, accompanied by a tingling or 
a prickling sensation, and characterized by rapidity of evolution and 
frequency of recurrence. 

The typical wheal is seen in the disease known as "nettle-rash" 
(urticaria), in which closely packed, shining, roundish, and whitish, 
pea- to finger-nail-sized elevations of the skin are visible, surrounded 
by a slightly rosy border. Wheals are firm to the touch, and arranged 
in patches, circles, bands, gyrations, or striatums, often disappearing 
in a brief time and recurring with or without a renewal of the cause. 
They are occasioned by a rapid exudation of serum into the rete or 
pars papillaris of the corium. The sensations produced are stinging, 
prickling, and itching. Wheals arc often surrounded by an areola. 

" Giant-wheals" are such as have the dimensions of a hen's egg, 
or cover extensive area- of integument, as, for example, the entire 
surface of a buttock or a shoulder. 

Relics of wheals which have disappeared arc usually transitory 
erythematous maculae, but in rare cases there is left a more or less deep 
pigmentation, which >lowly disappears (urticaria pigmentosa). 

At times the wheal-like condition is assumed by papillae, as also 
by lesions resulting from such traumatisms as the bites of insects, 
reptiles, horses, dogs, etc. 

Tubercula. — Tubercles {nodules; Fr., tubercules; Ger., Knoten) are 
circumscribed, solid, generally incompressible and persistent nodosities 
of the skin, varying in size from that of a coffee-bean to that of a 
cherry. 

Tubercles occurring in diseases of the skin bear no relation to the 
lesions having the same name which develop in pulmonary tuberculosis. 
The dermatologieal title relates chiefly to the size of the lesion. 

Tubercles may be projected largely from the free surface of the 
integument, or be deep-seated in the skin, and but a small portion 
become evident to the view externally. Their variations as to shape, 
color, size, slowness or rapidity of development, and other features 
correspond in great part with those described in connection with 
papules. They may be attached by a broad base to the skin, or be 
pedunculated, or even pendulous. Their seat is usually in the deeper 
portions of the corium or in the subcutaneous connective tissue. 
Degenerating and ulcerating tubercles are followed, as might be sup- 
posed in view of their volume, by considerable destruction of tissue, 
and correspondingly, in cases of repair, by extensive cicatrices. Tuber- 
cles are seen in such diseases as syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules, but the 



OBJECTIVE SYMPTOMS ~>7 

distinction between these two forms of lesions will better be recog- 
nized when attention is paid to the particular portion of the skin in 
which each takes its origin. Many tubercles arc pure neoplasms; 
others may l>c hypertrophies. Papules spring oftenesl from the 

superficial layers of the derma; tubercles, from the deeper layer-. 
At times a tubercle may project from the surface to a less extent 
than a papule, though its larger volume is evident as soon as the skin 
within which it has developed is palpated. 

Tubercles due to a cellular infiltration may cease to he circumscribed, 
and by coalescence furnish a diffuse involvement of both the skin and 
the subcutaneous tissue. 

Papulo-tubercles are transitional forms assignable to either of the 
two lesions named. 

Phymata. Tumors {tu mores; Ger., Geschwiilste; Fr., tumeurs) are 
masses of soft or solid tissue, or of solid tissue more or less commingled 
with fluids of variable consistency, differing in size, shape, color, and 
in the benignity or malignity of their career, located either within or 
beneath the skin, or, being attached to the skin, projecting from it to 
a variable extent. 

Tumors may be formed of blood-vessels or of lymphatic vessels, 
or of both in the same lesion; may embody large, fluid-containing 
cysts; may be built up of nerve-tissue, fat, bundles of connective- 
tissue fibers, glandular elements, and, indeed, of any of the elements 
which exist anatomically in the human integument. Tumors vary in 
size from that of a walnut to masses of enormous volume and weight. 
They may be pinkish, reddish, brownish, or even black in hue, and 
may be covered with a tense or flaccid extension of the integument. 

Examples of tumors are seen in fibroma, sarcoma, and carcinoma. 

Vesiculse. — Vesicles (j)hhjcten(B, phlyctenules; Ger., Blaschen) are 
acuminate, rounded, or flattened elevations of the superficial layers 
of the epidermis with limpid, lactescent, or sanguinolent fluid contents, 
varying in size from that of a poppy-seed to that of a coffee-bean. 

Typical vesicles are seen in the minute, transitory lesions occurring 
in the vesicular form of eczema. They may be discrete, grouped, 
transitory, or for days persistent. They may be developed from 
papules. They are usually filled with a clear serum. Variations from 
this type, however, are common. Thus, they may be either flattened, 
acuminate, roundish, umbilicated, or conical; may be fully distended 
or partially collapsed upon their contents; may have a short or long 
duration; may be distended with a milky, chylous, or blood-stained 
Quid; may be opalescent, yellowish, reddish, or blackish in color; 
several may coalesce to form a many-chambered bulla. One or 
several may undergo transformation into pustules or bullae. Vesicles 
may terminate by accidental or spontaneous rupture, their contents 
freely flowing forth upon the surface of the peripheral integument; 
or they may desiccate to a crust; or may even terminate by one o"h 
the ulcerative processes. They may or may not be accompanied by 
pruritus. Minute vesicles, which are merely the external apices of 



58 GENERAL SYMPTOMATOLOGY 

large-chambered accumulations of fluid beneath, occasionally form 
upon the surface of the skin. Such are seen in the course of lymphan- 
giectasis. 

Vesicles are found typically in herpes zoster, herpes simplex, vari- 
cella, dermatitis herpetiformis, dysidrosis 3 and several other cutaneous 
diseases. Vesico-pustules and vesico-bullse are intermediate forms of 
elementary lesions representing the types designated by these names. 

Pustulae.— Pustules (Fr., yustules; Ger., Pusteln) are circumscribed 
cutaneous abscesses, covered with an epidermal roof-wall, and varying 
in size from that of a millet-seed to that of a filbert. 

The typical pustule contains pus, and is colored yellowish, yellowish- 
green, or brownish-green, according to the admixture of its contents 
with blood. The pus, being an inflammatory product, necessarily 
indicates the occurrence of an inflammatory process at the base of 
the pustule. Pustules, like vesicles, may be roundish, acuminate, 
globoid, conical, or umbi Heated, and surrounded by an inflamed or 
normal integument; they may be superficial or be deep-seated; may 
terminate by rupture or by desiccation; may or may not be followed 
by an nicer and ultimate cicatrix. They may be seated either upon 
the free surface of the skin, or at an orifice of a follicle, in which latter 
case they represent an inflammation with purulent product in the 
duct or the gland beneath. 

Pustules may originate as such, or as a consequence of transforma- 
tion of vesicles, or after a change in a papule, which may thus come 
to have a purulent apex. According to Auspitz, they invariably origi- 
nate from vesicles. Pustules often result in the formation of crusts, 
the latter varying in color according as the pustules from which they 
originated contained clear serum or blood. 

Transitional forms between vesicles and pustules and papules and 
pustules are termed, respectively, vesico-pustules and papulo-pus- 
tules. Pustules of a large size, resting upon an indurated, engorged, 
and elevated base, are often called "ecthymatous." 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and 
many other cutaneous diseases, including several forms of dermatitis 
medicamentosa. Many contain pus-cocci; some furnish a sterile or 
pseudo-pus destitute of microorganisms. 

Bullae. — Blebs ("blisters;" Ft., bulks; Ger., Blaseri) are superficial 
or deep-seated elevations of the skin having fluid contents, differing 
in color, shape, and career, and varying in size from that of a coffee- 
bean to that of a goose-egg. 

Blebs have been described as large vesicles. They may contain 
serum, lymph, blood, or pus, and may variously be colored according 
to the degrees in which their contents become visible through a semi- 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic semicrescentic, or conical, and may even exhibit angles. 
They may be seated upon an apparently unaltered or an evidently 
morbid intt ment; and may or may not present a peripheral areola. 

Bullae ma} persist or may rupture; may desiccate or may degenerate 



OBJECTH E SYMPTOMS 59 

into ulcers; ma} collapse after the escape of their contents, and the 
roof-wall become glued to the base from which it was originally raised. 
Bullae usually occur in extremely debilitated states of the s; stem, and 
are. as a rule, of graver portent than other fluid-containing lesions of 

the -kin. They occur in scalds and hum-, in pemphigus, leprosy, 
sipelas, syphilis, and moist gangrene. 

Consecutive or Secondary Lesions. Squamae. Scales IV.. 
squames; Ger., Sckuppen) are attached or exfoliated epithelial lamellae 
which have become appreciable at the surface a- the result of some 
morbid process in the -kin. 

There i- constantly in progress over the superficies of the body 
physiological desquamation, the evidences of winch are not pro- 
nounced in -kin- properly cleansed by ablution. In morbid processes, 
however, desquamation may occur a- a distinct symptom in various 
form-. Thus the scales may be minute, fine, branny, dirty-white, 
or yellowish; they may be large, pearly-white, shining; may be dry 
or fatty; may be aggregated so a- to resemble flaky pie-crust; may 
exfoliate in extensive sheets, a- from the entire sole of the foot or 
the palm of the hand, or in glove-finger-like sheath-, as from the 
surface of a digit; they may be scanty, scarcely perceptible, and so 
firmly attached a- to require force for their removal: they may fall 
spontaneously in a pulverulent shower, being so abundant as to en- 
cumber the garments or the bed-clothing of the patient. 

Furfuraceous or pityriasic desquamation is that form in which fine, 
bran-like scales are shed from the surface. 

Scale- are frequently intermingled with other le-ions, often suc- 
ceeding the latter. Thus a papule may scale at its apex, or surround 
it- base with a collarette of loosened epidermal plates, beneath or 
between which a macular stain is visible. 

in, scales may develop upon macules, tubercle-, or tumor-. 
Though generally conceded to be evidences of a dry and non-dis- 
charging disease of the -kin, they are at time- accompanied or suc- 
ceeded by moisture of the part affected. 

The term scales i- sometimes applied to the flattened plate- of dried 
sebum that form on the >calp and on portion- of the trunk in pityriasis 
-teatoid- 

Scales occur in eczema, psoriasis, ichthyosis, syphilis, and in several 
of the parasitic diseases of the -kin. 
Crustee. -Crusts "scabs;" Ft., croutes; Ger., Krusten, Barken arc 

relic- of the desiccation of pathological product- of the -kin. 

Crusts usually contain epithelial debris and scales, and may be 
compounded with loosened hair- and foreign particle-. When formed 
by the desiccation of serum only, they are of a yellowish, straw- 
yellowish, or reddish-yellow hue; when composed largely of dried 
pus, they are colored greenish or greenish-yellow; and when there has 
been an admixture of blood they are usually brownish <>r blackish. 
At time- they suggest in appearance gum. honey, or Venice turpentine. 
In shape they may have the form of the concavo-convex lid of a watch- 



60 GENERAL SYMPTOM A TOLOGY 

case; in color and shape they may resemble the half-shell of an oyster 
or the carapace of a small turtle. They may be delicate and thin, 
bulky and thick, friable or mealy; may be firmly attached to the 
subjacent tissues or readily separable; may cover a sound though 
tender and reddened epidermis; may conceal a superficial or a deep, 
foul-based ulcer, by secretions from beneath which they are raised 
above the plane of the skin and increased in thickness; they may be 
circumscribed and no larger than a small finger-nail; may envelop 
an entire limb or organ, as the leg or the penis; or, finally, may be so 
irregularly disposed among other lesions papules, pustules, excoria- 
tions, and open ulcers — that it is difficult to define their outline, or 
even to recognize their identity. Ousts formed of dried sebum are 
greasy to the touch, dirty yellowish in shade, and usually seated upon 
a non-infiltrated base. 

Crusts are common in eczema, syphilis, leprosy, impetigo, and in 
a large number of other diseases «>f the integument. 

Excoriations. Excoriations {abrasions, erosions; Ft., excoriations; 
Ger., Hautabschiirfungen) are superficial solutions of continuity, 
usually involving portions of the skin affected with itching, and 
resulting from mechanical violence. 

Excoriations, in appearance among the most trivial of skin-lesions, 
possess a value from the diagnostic point of view which can scarcely 
be overestimated. They occur as striated, linear, punctate, circular, 
or irregularly shaped, furrowed wounds, at times involving areas of 
flat surface, oozing with serum or blood, covered with dried blood or 
crusts, yellowish, blackish, or reddish in hue, and for the most part 
both induced and accompanied by severe itching. They may coexist 
with hyperemia and infiltration of the skin beneath, brought on by 
the irritative character of the continuous, or, more frequently, inter- 
rupted, cause by which they were begotten. 

Excoriations become significant, depending upon whether they indi- 
cate scratching, tearing, or other species of wounding by the finger- 
nails, or the rubbing or piercing of portions of the integument with for- 
eign bodies. In the former case they are significantly recognized in 
those portions of the body most accessible to the hands, though in the 
case of eczematous children and infants they may originate by the rub- 
bing together of the knees, or the rubbing of one leg by the foot and 
toes of the other leg. The loss of tissue may extend deeper than the 
rete, at times invading the papillae of the corium, which bleed in con- 
sequence. Scars rarely result from any save the deepest excoriations. 

Excoriations may occur without the appearance of other lesions, 
as in the disease called pruritus; but where itching is severe and 
induced by a cutaneous exanthem, the lesions constituting the latter 
may be intermingled with, obscured by, or even obliterated by ex- 
coriations and the pathological processes to which they give origin. 
Thus, macules, vesicles, pustules, and papules may undergo change; 
and the recognition of the type of the existing disease may correspond- 
ingly be difficult. Excoriations are common in skins wounded by 



OBJECTH E SYMPTOMS 61 

lice, bed-bugs, ;ni<l gnats; in the subjects of eczema, jcabies, Inter- 
trigo, and prurigo; and in individuals with special sensitiveness of the 
integument to the action of a medicament employed cither internally 
or externally. 

Excoriations which occur after long-continued and persistent trau- 
matism of the skin may be the seat of secondary infection with a puru- 
lent product, may become the scat of a severe inflammatory process, 
may be surrounded with a vivid halo of redness, may be seated upon 
a dense infiltration, and may result in deep pigmentation of the skin. 

Rhagades. — Fissures (cracks, rimce; Ft., fissures; Ger., Hautshrunden) 
are linear solutions of continuity, usually occurring in previously 
infiltrated portions of the skin. 

Fissures may extend to the corium, and invade yet deeper structures; 
may be painful or the reverse; may be dry, secretory, or incrusted; 
are often hemorrhagic; and usually are formed with sharply cut walls. 
They are of frequent occurrence in the vicinity of the mucous outlets 
and the articulations, in which situations they are induced or aggravated 
by movements stretching or tearing tissue the extensibility of which 
has been diminished by any morbid process. Fissures may terminate 
in ulceration; they vary as to length, curve, and tenderness; they are 
often exquisitely painful, and greatly complicate the skin-disease in 
which they form; they may follow the curve traced by the boundaries 
of bodily organs near which they occur — as, for example, the line of 
the posterior junction of the ear with the head, or that of the breast 
of a woman with the thoracic wall upon which it rests. 

Fissures occur in eczema, syphilis, and other diseases. 

Ulcera. — Ulcers (Fr., ulceres; Ger., Gescliivure) are losses of substance 
resulting from a previous pathological process involving the corium, 
and in some cases the subcutaneous tissue. 

( utaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 
outline, a base, a floor, edges, and a secretion. The outline may be 
circular, crescentic, reniform, ovoid, serpiginous, or with horseshoe- 
like contour. The base, or underlying tissue, may be soft, supple, 
indurated, or in a state of active inflammation, with consequent 
infiltration. The floor may be glazed, shallow, deep, excavated, 
cup- or funnel-shaped, "worm-eaten," crateriform, sloughy, covered 
with a tenacious or a readily removed secretion, granular, puriform, 
or hemorrhagic. The edges may be clean-cut, having a punched-out 
appearance, undermined, everted, ragged, irregular, or contracting, 
\\ ith a whitish inner border of advancing cicatrization. The secretion 
may be scanty, limpid, puriform, profuse, ichorous, and odorless, or 
exhale an offensive smell. Ulcers may be so crust-covered as to be 
invisible, or so exposed and erosive in action as to render the affected 
surface in the highest -degree unsightly. They may be acute or 
chronic; insensitive or productive of intense pain; may heal by cica- 
trization, remain open for a lifetime, or prove fatal either by destruc- 
tion of parts essentia] to life or by exhaustion of the vital forces. 



62 GENERAL SYMPTOMATOLOGY 

Ulcers occur in syphilis, leprosy, lupus, and carcinoma. They occur 
on the lower extremities as the result of secondary infection associated 
with the congestion due to varicose veins; also in hypostatic congestion 
(bed-sores), and in cases of general debility with impaired resistance. 
Ulcers terminate after healing- with cicatrization. 

Cicatrices. — Scars (Fr., cicatrices; Ger., Narberi) are connective-tissue 
new-formations replacing tissue lost through destructive processes 
involving the corium. 

Scars never succeed excoriations, fissures, or other solutions of 
continuity in the skin that have not penetrated as far as the corium 
and resulted in destruction of a portion of the elements of which the 
corium is built up. They possess the highest importance for the 
diagnostician, since they point invariably to a pathological process 
the career of which is terminated, the characteristic features of which 
termination they frequently embody. They may be regarded as the 
special and persistent imprints upon the integument of the serious 
disorders from which it has suffered. 

To a certain extent, as already shown, scars retain traces of the 
special peculiarities of the lesions, and even of the diseases, which 
they succeed. The identification, however, of the individual prede- 
cessor in each instance is, in the present state of our knowledge, not 
always possible from a study of cicatrices alone. The extent of knowl- 
edge in this direction, however, is rapidly increasing; and in many 
cases the certainty thus acquired is of incalculable value to the 
diagnostician. 

Scars may be minute, punctate, or extensive in area, attached to 
the underlying tissues, depressed, or raised above the plane of the 
peripheral skin, seamed with furrows, pliable and soft, or indurated, 
traversed by ridges, knotted, or as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular 
prolongations toward contiguous portions of the skin; and by subse- 
quent contraction induce considerable distortion and deformity. Thus, 
they may drag down an eyelid, and ectropion ensue; may glue the 
lobe of an ear to the cheek; may evert the lip or nostril. When recent 
they are usually reddish in tint; when older they may be pigmented 
in the centre or at the circumference; or, as is common, may exhibit a 
gradual decoloration centrifugal in progress. They may be the seat of 
pain from an entrapped nerve-filament; may reopen to ulceration; or 
may be unaccompanied by subjective sensation. Not rarely they be- 
come the source of keloid. Scars are unprovided with hairs, papillae, 
or the orifices of sweat-pores and sebaceous-gland ducts. As implied 
in the definition given above, scars may result from any disease or 
injury to the skin that involves loss of connective-tissue elements 
of the corium. 

Unclassified Lesions. — To the several lesions defined above, Bazin 
adds, as elementary forms, the mucous patch of syphilis, the cuniculus 
or furrow produced in the skin by the Acarus scabiei, and the sulphur- 
colored crusts of favus. Among the elementary lesions of the skin, 



OBJECTIVE 8Y WPTOMS 

Brocq includes the gumma, or firm, deeply situated, often ubcutaneou 
mass commonly degenerating centrally rather than, as may the 
tubercle, from without; while among the consecutive or secondary 

lesions of the skin the same author considers " lichenization" or 
"lichenification." These are terms chiefly employed by French 
writers to designate the changes in the skin produced by long-con- 
tinued external irritation, the thickened and infiltrated integument 
assuming- a yellowish-brown or reddish-brown tint, the exposed surface 
being studded with pinhead, pinpoint, or slightly larger, shining 
and flattened isolated elevations, with delicate furrows separating 
each from the other. These, however, are not general, but special 
features of individual disorders, and are best studied in connection 
with the latter. 

The elementary lesions of the skin are termed by Auspitx anthem- 
(ifn; groups of such lesions, synanthemata; and, in accordance with 
common usage, generalized eruptions affecting the entire surface of 
the body, exanthemata. The word erythanthema is used to describe 
groups composed of several of the elementary lesions of the skin, as, 
for example, of papules, vesicles, and pustules, rising from a common 
reddened and hyperemic base. 

In addition to the names of the lesions of the skin just enumerated, 
certain peculiarities of cutaneous symptoms are described in qualify- 
ing terms which require definition. They relate chiefly to the color, 
shape, distribution, and method or period of evolution of lesions as 
they are observed in individual cases. The more important of these 
terms, as used by modern writers, are alphabetically arranged below, 
with a brief explanation appended to each. 

Abdominalis. Located on the abdominal surface. 
A.CQUISITUS. Acquired. 
A< i minatus. Having a pointed apex. 
Acutus. Of acute course. 
Adultorum. Occurring in adult years. 
l.-i i\ \ lis. Occurring in the summer season. 
Aggregatus. Collected in patches. 
A.GRTI s. Acute, or angry in appearance. 
Albidus. Of whitish color. 
A \(iii;eTATicus. Vascularized. 

ANNULATUS. \ t xu r e 

A xm laris. ) In the form of a ring. 
Ai'viuoTicus. Unaccompanied by fever. 
Abeatus. Occurring in areas. 
Autii •■!« i \lis Producible artificially. 

Asymmetricalis. Of different distribution on the two lateral halves of the body. 
\> ii \i\ \i.is. Occurring in the autumn. 
Brachi mis. Occurring on the surface of the arm. 
Cachecticorum. Occurring in debilitated subjects. 
CAPITIS. Occurring on the head, usually the scalp. 
( ' \\ BRNOSUS. Large chambered. 
CHRONICUS. Chronic in course. 

< JlRCIN vns. Of circular outline. 

< JlRCl MSCRIPT1 s. Having a definite 1 contour. 

( lONFERTUS. 1 v i-i • "•, ■ i i r i 

Confli ens Arranged in close proximity, with coalescence ot lesions. 
Contagiosus. ( Japable of transmission by contagion. 



64 GENERAL SYMPTOMATOLOGY 

Corporis. Occurring on the surface of the body; employed usually to designate 

an eruption upon the trunk, as distinguished from that on the head or t he 

extremities. 
Crustosus. Crusted. 
Crystallintjs. Of crystalline appearance. 
Diffusus. Irregularly disposed. 
Discretus. Having isolated lesions. 

Disseminatus. Disseminate: without regularity of distribution. 
Eruption. Is used of the totality of all patches and lesions upon the person of 

one individual. 
Erythematosus. Having a reddish blush. 
Essentialis. Idiopathic. 
Exfoliatiyus. Having a tendency to exfoliation or shedding of Bcales from the 

surface of the body. 
Exulcerans. Exhibiting lesions with a tendency to superficial ulceration. 
Facialis. Located on the face, usually as distinguished From the scalp. 
Favosa. Displaying crusts of faviis. 
Febrilis. Accompanied by a febrile proot as, 
Femoralis. Occurring on the surface of the thigh. 
Fibrosus. Composed of fibrous tissue. 
Figuratus. Having a figured appearance. 
Flavescens. Of yellowish hue. 
Foliaceus. Resembling a Leaf or leaves. 
Follicularis. Concerning 1 he cutaneous follicles. 
Fungoedes. Resembling a fungus. 

!• i in i i;\« ii - Exhibiting numerous tine, bran-like scales. 
GuTTATUS. Of the size of a drop of water. 
Gyrattjs. Saving a serpiginous or gyrate outline, which is usually the result 

of a coalescence of imperfect circles or semicircles. 
Herpetifobmis. Vesicular or herpetic in type. 

HlEMALIS. Occurring in the winter season. 
Humidus. Accompanied by moisture. 
Hypertrophic is. Characterized by hypertrophy. 

Hystrix. Having lesions projected <>i erected like quills. 

Imbricatus. With crusts or scales overlaid like tiles. 

Impetiginodes. Pustular. 

Infantilis. Occurring in infancy. 

Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric, rings. 

Labialis. Occurring upon the surface of the lip. 

Lenticularis. Of the size of a small bean. 

Lividus. Deeply colored. 

Maculosus. Discolored. 

Madidans. Characterized by moisture. 

Marginatus. Having a defined margin. 

Medicamentosa. Produced by external or (more commonly) internal medication. 

Melanodes. Of blackish color. 

Miliaris. Of the size of a millet-seed. 

Mitis. Of mild, benignant type — the reverse of agrius. 

Multiformis. Exhibiting simultaneously several types of elementary lesions. 

Neonatorum. Occurring in the newborn. 

Neuriticus. Having nervous association. 

Nigricans. Of a black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 

Nummularis. Of the size of small coins. 

Oleosus. Accompanied by an oily secretion. 

Palmaris. Occurring on the palms. 

ptSte™™^ S ' r Produced by an animal or a vegetable parasite. 

± AJtvAol ilC Uo. J 

Patch. The aggregation of several isolated or confluent lesions. 

Phlegmonosus. Accompanied by deep-seated inflammation. 

Phlyct^enoides. Characterized by groups of small vesicles. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Related to the hair. 

Plant aris. Situated on the soles of the feet. 

Planus. Flat. 



OBJECTIVE SYMPTOMS 65 

Polymorphous. The Greek equivalent of the Latin multiform 

Pr/eputiaus. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfacef of the genitalia 

Pruriginosus. Accompanied by itching. 

Pi bis. Located upon tin- skin or hairs of the pubes. 

Pi ntctati s. Occurring in dots or points. 

Rhagadiformis. Fissured, or tending to produce fissures. 

Rosacei s. Having s rosy or pinkish hue. 

I!i ber. Red ; usually dark red in color. 

SCUTTFORMIS. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis^ Occurring in advanced years. 

Serpiginosus. Literally, creeping; advancing in irregular gyrations. 

Sk < i s, Dry; unaccompanied by moisture. 

Solitarius. Exhibiting an isolated lesion, or with isolated lesions. 

SYMMETRIC ALIS. Similarly distributed on the lateral halves of the body. 

Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

I M\ ersalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Variegatus. Exhibiting several distinct colors. 

\ usculosus. Accompanied by vascular development. 

Vernalis. Occurring chiefly in the spring of the year. 

Versicolor. Exhibiting several shades of the same color. 

\'i LGARIS. Of the usual or commonly observed type. 



II I. GENERAL ETIOLOGY 



Several features must be considered in the study of the causation 
of cutaneous diseases. A Large number of the latter are simplj ex- 
pressions on the skin of a constitutional disease (the exanthemata: 
syphilis, pellagra, the xanthomata, and other diseases of tins type). 
Others are purely cutaneous diseases, the entire process, including 
the cause, being limited to the skin (scabies, pediculosis, impetigo, 
and other parasitic diseases whose causative factor has been demon- 
strated). Still others, while purely skin diseases, have general con- 
ditions which contribute either to their cause or continuance (acne 
rosacea, seborrhea, eczema). Finally, many are cutaneous expres- 
sions of constitutional disturbances due to toxins other than those 
produced by a specific infection (acne, erythema multiforme, the 
purpuras, scorbutus, etc. I. 

A very important matter in relation to the general cause of cutaneous 
disease is the question of individual susceptibility. Of the many 
persons exposed to poison ivy, only a few develop a dermatitis venenata 
from such exposure; and a small proportion of these have their 
skins so sensitized that many and varied external and internal irri- 
tations will induce a subsequent dermatitis or eczema, that before 
the attack of the original trouble would have been inoperative. Idio- 
syncrasy has been the term employed to indicate this susceptibility 
from ingestion of certain drugs. The workers in anaphylaxis have 
thrown some light on this subject, but much more is needed. The 
fact remains that such susceptibility exists and must be taken into 
consideration. 

Environment. — Environment is an important factor in the general 
etiology of cutaneous disease. Under this topic is immediately sug- 
gested the care or lack of care of the skin. Personal hygiene is very 
important, both directly and indirectly, as a factor in the production 
of skin diseases. Bathing, when overdone or employed insufficiently, 
often produces skin disease. In infants that are over-bathed intertrigo, 
eczema, and the like are often caused. The temperature of the water 
is important, as is demonstrated frequently in the excessive use of 
hot baths by young women, which is a factor in the production or 
aggravation of acne and seborrhea. The lack of bathing, as exhibited 
in public practice, predisposes to all parasitic diseases. It is a matter 
of common experience that pus-infection, some types of eczema, 
impetigo, and other diseases of this class occur much more frequently 
under these conditions. Poor air is indirectly a factor. This probably 
(66) 



FOOD 61 

produce n effecl through the lowering of the general vitality, rather 

than by direct local action. In the crowded apartment- of the lower- 
classes, the lack of fresh air plays a part in all diseases, including those 
peculiar to the >kin. Clothing plays its pari through local irritation, 

when the material \\>vd next to the skin is either rough or poorly dyed. 
A-n in, when too warmly clad, the skin becomes tender, and there- 
fore more liable to external and internal irritation. As a general 
rule, woolen clothing should not he worn next to the skin; cotton, 
linen or silk is preferable. 

Occupation. Many dermatoses are due exclusively to the occu- 
pations of men and women. The workers in dyes, in chemicals, and 
in drugs sutler in one way; the men who handle tiles, hricks, mortar, 
or clay in another; the haker, the confectioner, the cook, the laundress, 
the green-grocer, the seamstress, the shoemaker, the carpenter, and 
the machinist have each their forms of erythema, dermatitis, kera- 
tosis, or induration. Similarly, those whose faces are much exposed, 
as the wheelmen of vessels, tramcar-drivers, locomotive-engineers, 
and day laborers, exhibit symptoms in that region. Butchers, wool- 
workers, cattlemen, and sheep-shearers are liable to contract glanders, 
ringworm, or malignant pustule. Those who handle the bodies of 
the dead are prone to tuberculosis of the hands (anatomical tubercle), 
and those compelled to stand much of the time are exposed to the 
consequences of varicose veins of the legs and resulting eczema 
of that region. Finally, the dermatitis of the hands of laboratory 
workers produced by formalin, and of surgeons and nurses produced by 
the irritating substances used to cleanse the hands preliminary to 
surgical work, are of comparatively frequent occurrence. 

Scratching is a potent factor in inducing and aggravating cutaneous 
disease. In pruritus, scratching frequently produces a traumatic 
dermatitis of varying grades. The aggravation of an eczema by 
scratching is a matter of daily observation. In this connection, other 
agents producing trauma with deleterious effects upon the skin should 
l»e mentioned, as the bites of insects, such as lice, fleas, bed-bugs; 
of animals, such as horses, dogs, and cats; and of serpents. In addi- 
tion to the purely traumatic effect of all of these may be added the 
introduction of a toxic agent; and, finally, self-inflicted injuries must 
be recognized. 

Food. — Food is another important factor, as many toxic erythemas, 
urticarias, and other angioneurotic disturbances are produced through 
errors in diet. This may be caused in several ways. Toxic substances 
formed in the food itself may be absorbed and be the factor. Keflex 
irritation from indigestible articles is the active factor in other cases. 
Idiosyncrasy is an important factor in still others where neither of 
the above plays any part. In searching for articles that commonly 
produce harm, the following should be inquired into: canned foods 
of all sorts, fish, lobsters, cheese, nuts, and strawberries. Medicine, 
while given innocently by physicians and taken also by patients of 
their own accord, is a very common factor in producing skin disease. 



68 GENERAL ETIOLOGY 

A reference to the chapter on Dermatitis Medicamentosa will demon- 
strate this fact. Most of the drugs, while capable of producing erup- 
tions, do not produce characteristic ones. The iodids, hromids, 
and arsenic, however, are exceptions. 

Climate and Seasons. — Certain diseases exist only or mainly in 
tropical countries. The list of exclusively tropical diseases is decreas- 
ing, however, and particularly during the last few years. Pellagra, 
hitherto practically limited to the so-called warm countries, has 
recently been fairly prevalent in the United States. Certain other 
diseases occur largely in or are made worse by cold weather. 1 In this 
connection, the season^ also play an important part. In winter, 
psoriasis, pruritus hiemalis, and certain types of eczema flourish; 
in the spring and autumn, erythema multiforme and pityriasis rosea 
are prevalent; while during the summer, dermatitis venenata, hydrba 
sestivale, certain types of eczema, dysidrosis, and sudameii are of fre- 
quent occurrence. 

Heredity. In certain diseases, such a- ichthyosis, angioneurotic 
edema, xeroderma pigmentosum, congenital Lymphodermia, keratoder- 
mia, and others, heredity i> a factor. It is difficult to state whether 
some of these are hereditary disorders or arc family diseases. It is 
uncommon to find xeroderma pigmentosum in different generations, 
but it is very common for several members of one family to be affected. 
On the other hand, ichthyosis apparently occurs in many generations, 
and in addition in several members of one generation. Keratodermia, 
on the contrary, may be limited to one member of a family, and yet 
examples occur where heredity seems to be important. In tuberculosis 
of the skin, a predisposition in certain families is assumed, but infec- 
tion with the bacillus of tuberculosis must occur, though the soil may 
have been prepared by heredity. In very many other cutaneous 
disorders the influence of heredity remains a matter of opinion, which 
at present cannot be proven in either direction. 

Race. — Very few diseases are prone to attack a single race. It is 
well known, however, that keloids occur often and grow to immense 
proportions in colored people, and that among these leucoderma is 
also common. Again, idiopathic multiple pigmented sarcoma is 
largely limited to the Jewish race. Most other disorders appear to 
occur without much selection as to race. 

Age. — Infancy is characterized by the occurrence of congenital 
disorders, in addition to which several other cutaneous diseases are 
especially liable to occur. Among the commonest diseases may be 
mentioned the following: nevi, xeroderma pigmentosum, xanthomata, 
ichthyosis, epidermolysis bullosa, sclerema neonatorum, urticaria pig- 
mentosa, ringworm (the small-spored variety), favus, lupus vulgaris, 
certain types of eczema, particularly pustular, and pus infections. 

1 Cf. Hyde: "On Affections of the Skin Induced by Temperature Variations in Coid 
Weather," Chicago Med. Jour, and Exam., 1885, 1, p. 187, and 1886, lii, p. 116; Cor- 
lett, Jour. Cut. Dis., 1894, xii, p. 457, and Jour. Amer. Med. Assoc, 1902, xxxix, p. 
1583. 



PARASITIC DISEASES ()fl 

At puberty, acne, seborrheic dermatitis, and other jebaceou -gland 
disorders occur; while ;it ii more advanced age epitheliomas are 
common. 

Physiological State. A( the menstrual epoch, certain diseases are 
made worse, while others apparently occur only al thai time. 
Eczema recurring regularly at this period is occasionally noted. Acne 
and rosacea may be aggravated. In pregnancy, herpes gestationis 
may occur, and if so recurs with each subsequent pregnancy. Pruritus, 
particularly localized in the genital region, urticaria, and chloasma 
arc all apparently induced by this state. Other cutaneous disorders, 
such as acne and eczema, may be either aggravated or improved. 
At the menopause, pruritus and hypertrichosis not infrequently occur. 

The relationship of cutaneous diseases to the so-called general 
disorders is a matter that has been studied much of late. Many gen- 
eralizations are made. Specific connection between a general disorder 
or condition and cutaneous disease is rarely demonstrated. Xanthoma 
occurs with diabetes, as do also pruritus, both generalized and 
local, and genital eczema. That there is some connection between 
the gouty state and eczema there can be little doubt in certain cases. 
Again, urticaria is a fairly common accompaniment of malaria, and 
in rheumatism purpura is occasionally found. The extreme pruritus 
accompanying jaundice induced by hepatic disease is a matter of 
common observation. 

Transmission of Infectious Diseases. — Infectious diseases with 
cutaneous manifestations are communicable from man to man, or 
from animal to man, in a variety of ways. Thus, transmission 
may occur by actual contact, either with the infected person or 
animal, or through an intermediate object, such as a drinking cup, 
roller-towel, or article of clothing. This mode of infection is an impor- 
tant factor in the spread of the tineas, a variety of tuberculosis of the 
skin known as the "anatomical wart," the acute eruptive fevers, lepra, 
and, most important of all, syphilis. Or it may take place through 
inspired air which has become infected by droplets of sputum from the 
respiratory passages of tuberculous patients, or by desquamation from 
scarlatina. In these last-named diseases ingestion of contaminated 
food, particularly milk, is a well-recognized mode of transmission. 

Many diseases are transmitted by the medium of insects (particu- 
larly the fly, the bed-bug, the louse, the flea, and the mosquito), which 
attack the skin and deposit in the solutions of continuity which they 
produce bacteria or other noxious germs derived from foreign bodies 
on which they previously have alighted. In this connection, relative 
to diseases with cutaneous manifestations, may be mentioned Rocky 
Mountain spotted fever, transmitted by a tick; typhus, by the louse; 
and lepra, by the bed-bug. 

Parasitic Diseases. Under this title were once included solely the 
dermatoses induced by the presence of the animal and vegetable para- 
sites. Among the former may he named scabies and pediculosis; 
among the latter, ringworm of the scalp and of the beard. Hut the 



70 GENERAL ETIOLOGY 

term "parasite" has acquired a much wider scope since the recognition 
of the microorganisms which have been demonstrated to be efficient 
in the production of a long list of cutaneous affections. Among these 
may be named the bacilli productive of cutaneous tuberculosis and of 
lepra; the pus-cocci, responsible for the several forms of impetigo and 
pustular eczema; and the streptococci, recognized in several forms 
of dermatitis. In most of the dermatoses which are recorded today 
as parasitic, germs have been recognized which, either singly or in 
cooperation with others, have been proved to be effective in the 
production of these disorders, or have been demonstrated to play an 
active part in either their extension or exacerbation. 

The popular ideas respecting the frequency and danger of con- 
tagion in diseases of the skin are often erroneous. The non-parasitic 
affections are, and probably always will be, more numerous than all 
others. The danger of communicating scabies, syphilis, and other 
affections by handshaking i- not a- great a- i- generally believed. On 
the other hand, the dangers which by the mass of people are little 
considered are often the graver and more to be avoided. Among 
these may bo mentioned the use of the public roller-towel, the drink- 
ing in common from public cups and glasses, promiscuous kissing, 
contact with the lower animals exhibiting diseases of the hide or fur, 
the wearing of a stocking on one foot which the day before was worn 
over the surface of a fellow-ineiiiber, the seal of disease, and the 
wearing of velvet- or fur-trimmed collars on top-coats after the occur- 
rence of a disease of the skin of that part of the neck with which the 
garment is naturally brought into contact. 



IV. GENERAL I'ATIIOMKJY. 



The pathological processes occurring in the skin arc similar in many 
diseases to those occurring in other organs; but, owing to complicated 
structure and functions, the integument has a pathology peculiar to 

itself. Various pathological conditions, such as inflammation, hyper- 
emia, anemia, hypertrophy, atrophy, degeneration, and neoplasms, are 
found in the skin, as in other organs of the body. Some diseases, 
such as the toxic erythemas, are merely cutaneous manifestations of an 
internal disorder which often exhibits no demonstrable internal lesions; 
in others, such as lupus vulgaris, the pathological and clinical mani- 
festations are for the most part limited to the skin. Again, in dis- 
eases such as syphilis, similar pathological changes may be noted both 
in the internal organs and in the skin. 

Bacteria. — The skin furnishes a habitat for a large number of 
bacteria, both pathogenic and non-pathogenic. From the normal 
skin may be collected a number of varieties of cocci, bacilli, and yeasts. 
Many diseases of the skin are demonstrably of bacterial origin, while 
others are probably due to specific microorganisms not yet recognized. 
Schizomycetes (tuberculosis, leprosy), streptotrichese (actinomycosis), 
blastomycetes (blastomycosis cutanea), hyphomycetes (favns, "ring- 
worm") are all concerned in the production of diseases in the skin or 
its appendages. Animal parasites are responsible for several disorders 
(scabies, pediculosis). 

Hyperemia. — Hyperemia in the skin may be active or passive, 
local or general, transient or persistent. On account of the condi- 
tions which may be associated with hyperemia, it plays an important 
part both in cutaneous and general pathology. Galloway 2 has empha- 
sized the importance of erythema as an indicator of disease. 

Anemia. — Anemia may be general or local. It is not a frequent 
factor in the production of cutaneous disease. Generalized anemia 
is a symptom of several diseases of the blood. Local, transient anemia 
occurs in urticaria and when cold is applied to the integument. 

Inflammation. Some of the many phases and pathological changes 
of the process recognized as inflammation arc present in the majority 
of cutaneous diseases. Primarily, there occurs vascular dilatation, 
with leukocytic infiltration and exudation of plasma. The leukocytes, 



' For a more complete discussion of the pathology of the -kin. sit MacLeod, 
Pathology of the Skin; lima, Eistopathology; Darier, I. a Pratique Dermatologique, 
pp. (17 136. 

1 Brit. Jour. Derm., 1903, w. p. 235. 

71 



72 GENERAL PATHOLOGY 

attracted by positive chemotaxis to the point of irritation, either 
remove the offending material (microorganisms, etc.) by phagocytic 
action, or themselves are overcome, undergo fatty degeneration, and 

become converted into pus-cells. The chemotactic agent may be a 
mechanical, chemical, or thermic irritant, or its cellular products. The 
toxins of microorganisms may be effective. The plasma dilutes the 
toxins, and by depositing fibrin through the action of a ferment helps 
limit the process. Varying with the degree of the reaction and its 
attendant conditions, numerous secondary epidermal changes occur. 

Histology. —The epidermis and corium, being unlike in develop- 
ment and structure, undergo different pathological changes. 

The epidermis is composed of epithelial cells in various stages of 
evolution, from the columnar, nucleated, and comparatively highly 
differentiated cell of the basal layer of the rete mucosum, to the flat 
and lifeless external cells of the stratum corneum. A knowledge of 
the normal process of evolution of these cells is necessary to an under- 
standing of the changes which necessarily must occur in morbid condi- 
tions when the normal course of evolution is interrupted by some 
mechanical, chemical, or other agency. Each cell progresses from the 
basal layer of the rete through the several strata above until it reaches 
the superficial pari of the stratum corneum, having on it> way passed 
through various stages and performed different functions. After com- 
pleting its cycle of existence, it is finally cast oil'. 

In the basal layer are situated the mot hcr-cells of the epidermis. 
They are columnar in shape, contain nuclei and pigment, receive the 
termination of non-inedullated nerve-fibrils, and have extending from 
them prolongations of protoplasm called prickles. As they progress 
upward through the rete, they become gradually flattened, no longer 
contain pigment (in the white races), and on reaching the granular 
layer are filled with granules of keratohyalin, upon the perfect forma- 
tion of which depends the normal process of cornification. Farther up, 
the cells become homogeneous and lose their keratohyalin, but acquire 
eleidin in the stratum lucidum. In the lower part of the stratum 
corneum their nuclei disappear and a horny substance, termed keratin, 
is formed, to which substance this layer owes its hardness. Here also 
some fat appears. Still more externally, the cells become entirely 
flat and lifeless, and eventually are shed. 

Hyperkeratosis — Acanthosis. — One or all of the layers of the epi- 
dermis may be involved in pathological processes, depending upon 
the character of the change and its cause. When there is overgrowth 
(hypertrophy), either local or general, of the stratum corneum, it is 
designated as a hyperkeratosis, examples of which are seen in kerato- 
dermia and ichthyosis. 

By acanthosis (Unna) is meant a benign hypertrophy of the rete, 
in which the fibrillary structure of the cell is retained. Acanthosis 
occurs in all the infective granulomata, including syphilis and tuber- 
culosis. Malignant hypertrophy of the rete occurs in epithelioma, 
in which affection the normal rete-pegs are not only enlarged and 



FIBROUS IND CELLULAR STRUCTl RE OF THE 

elongated (acanthosis), bu1 there are also rupture of the ba al layer and 
irregular infiltration into the corium of epithelial cells, which lose their 
fibrillary structure and often become so changed as t<> resemble cells of 
me3oblastic origin. 

Atrophy. Atrophy of the cells of the epidermis occurs under various 
conditions. It may be caused by pressure, either external f ;i- from a 
truss) or internal (neoplasm beneath the skin). It is found commonly 
in the senile skin, and is marked in eases of diffuse idiopathic atrophy 
of the skin. 

Parakeratosis, Production of Vesicles, Bullae, and Pustules. 
Edema occurring in and between the rete-cells interferes with the 
formation of keratohyalin in the granular layer, causes the cells of 
the stratum corneum to appear swollen and moist and to retain their 
nuclei, and prevents the formation of keratin. This condition is 
termed "parakeratosis" (Unna), and is found in typical development 
in eczema and psoriasis. When the edema becomes greater, collec- 
tions of fluid form, usually in the rete, and thus vesicles are produced. 
They are called "parenchymatous" when the early edema is intra- 
cellular, or " interstitial" if it be intercellular. Vesicles may be located 
superficially in the rete, as they usually are in eczema; or deeper, 
as in dermatitis herpetiformis; or beneath the epidermis, as occa- 
sionally happens in herpes zoster. Vesicle-formation is dependent 
not only on the mechanical separation of the cells by edema, but also 
upon the presence of toxic and other substances in the lymph, which 
may produce separation and disintegration of the epithelial cells, and 
thus leave spaces. Bulla? similarly are formed and located, and differ 
from vesicles chiefly in being .larger. A typical bullous disease is 
I pemphigus. When a large number of leukocytes collected in a chamber 
by chemotactic or other action have undergone fatty and other degen- 
erative changes, the lesion becomes a pustule. When edema is long 
persistent, such as occurs when the leg is the seat of varicose veins, 
the epidermis is destroyed entirely and ulceration results. 

Epithelial Degeneration. — The cells of the epidermis are subject 
to degenerative processes, the one most studied being of the "hyaline" 
type. This occurs in carcinoma and also in several other diseases, but 
is not, as once was believed, pathognomonic (see cellular degenera- 
tions of the corium). Degeneration occurring in epithelial cells ex- 
posed to .r-rays, though not definitely classified, is pronounced and 
important. The nucleus as well as the cellular protoplasm is affected. 
The cell is swollen, stains poorly, becomes vacuolated, and eventually 
completely disintegrates and is carried away by leukocytic action 
(hiring the period of reaction. 1 

Fibrous and Cellular Structure of the Corium.- The corium is 
mesoblastic in origin, and is composed of fibrous tissue and cellular 
elements. The white fibrous bundles are called collagen, while the 



'Seholtz, \rcliiv. 1902, lix. pp. 87 and 241. Abstr Brit. Jour. Derm. 1902, riv, 
397. 



74 GENERAL PATHOLOGY 

yellow elastic fibers are termed elastin. The cells found normally 
in the corium are connective-tissue, mast-, and vacuolated cells. As 
cellular pathology is so important in cutaneous disease, some knowl- 
edge of the minute structure of normal and pathological cells is 
important; 

The common types of connective-tissue cells are large, spindle- 
shaped cells, which vary both as to size and shape. They have ex- 
tending processes, which connect with those of neighboring rolls. 
The nucleus is surrounded by a membrane, is usually cither oval or 
round in shape, and is said to be vesicular on account of its open appear- 
ance, which is due to large spaces found between the chromatin threads. 
This open structure causes it to stain less deeply than the more com- 
pact nucleus of the mononuclear leukocyte, with which it is often 
confounded. In young connective tissue the cells are small and more 
or less oval, have a nucleus as above described, are surrounded by 
cell-protoplasm, and are termed fibroblasts. Other and less common 
varieties of connective-tissue cells are described by I Una as plate- 
cells. 

Vacuolated cells of the corium have nuclei similar to those of 
ordinary connective-tissue cells. The cell-protoplasm presents spaces 
or vacuoles, but has no processes extending from it. On account of 
mitoses occurring in these cells, and because their apparent function 
is that of reproduction and not of evolution into connective tissue, 
MacLeod suggests that these may be the mot her-cells of the corium, 
being thus analogous to the cells of the basal layer of the epidermis. 

Mast-cells in the coriinn resemble other connective-tissue cells, but 
differ from them in that they contain a number of basophilic granules. 
They are discussed more fully in connection with the pathological cells 
of the corium. 

Pathological Cells of the Corium. — Plasma-Cells. — Before Unna 
described the cell now generally recognized as the plasma-cell, at 
least two classes of cells were so denominated. The term is now 
restricted to cells which vary in size from that of a leukocyte to that 
of a cell two or three times as large. They are rounded or oval in 
shape and contain a large amount of protoplasm. The nucleus is 
usually eccentrically placed and corresponds in shape to that of the 
cell. It may be vesicular in appearance, or again several deeply 
stained masses of chromatin may be arranged about its border. Two 
nuclei are occasionally present. A cell having a similar nucleus, but 
containing a small amount of protoplasm, is found abundantly in 
tuberculosis, but is considered by many to be a lymphocyte. Plasma- 
cells are found abundantly in the infective granulomata, and to these 
cellular infiltrations Unna applied the term granuloma. Unna main- 
tains that plasma-cells originate from connective-tissue cells, while 
Jadassohn, Councilman, Krompecher, Schottlander-Vmarschalko, and 
others believe that they arise from leukocytes. Krompecher, Vmar- 
schalko, and others agree that these cells evolve into connective 
tissue, thus admitting the formation of connective tissue from leuko- 



DEGENERATIONS OCCURRING IN THE CORIUM 75 

cytes. 1 Plasma-cells arc studied besl when -tinned with polychrome- 
methylene-blue (Unna), or Pappenheim's compound stain of pyronin- 
methyl-green. In the Former, metachromatism is shown by the nucleus 
taking a blue color, while the protoplasm is stained a blue violet. 

Giant-Cells occur in typical development in tuberculosis, but are 
Pound to a degree in syphilis, and cells resembling them may be noted 
in several chronic inflammatory diseases of the skin. The tubercular 
giant-cell may be round, oval, or irregular in shape, depending some- 
what on its surroundings; as, for example, the presence of collagen, 
elastin, etc. They vary in size from two to three to many times the 
dimensions of a leukocyte. They contain nuclei which are similar 
to those of plasma-cells; and which may be arranged at one or both 
ends or sides, or completely around the periphery of the cell, and may 
number from a dozen or less to more than a hundred in a single cell. 
They stain deeply, thus making a contrast with the poorly stained 
(•(Mitre of the cell, which presents a homogeneous protoplasm, As to 
their origin, several theories are advanced. One is that they are 
formed by the rapid proliferation of the nuclei in a single cell without 
corresponding division of the protoplasm. A second is that a number 
of cells surround some irritant, such as tubercle-bacilli, and coalesce, 
thus producing the multinucleated giant-cell. The question whether 
the giant-cell originally comes from connective-tissue cells or from 
leukocytes cannot be answered until the origin of the plasma-cell has 
been determined. 

Mast-Cells occur to some extent in the normal corium, and are found 
in increased numbers in some diseases, including the infective granu- 
lomata, in which they are not specially significant. In urticaria pig- 
mentosa, however, their increase is so marked as to be pathognomonic. 
They may be produced rapidly, as was demonstrated by Gilchrist,' 2 
who noted that they formed synchronously with an urticarial wheal. 
They may assume the shape of a connective-tissue cell, plasma-cell, 
or lymphocyte, and may originate apparently from any cell found in 
the corium. Their chief characteristic is the presence of basophilic 
granules in the protoplasm. Mast-cells of the corium correspond in 
staining reactions to Ehrlich's mast-cells of the blood, but it does not 
follow that those present in the cutis come from the blood. They 
are demonstrated best by stains having metachromatic properties, 
such as polychrome-methylene-blue (Unna), which stains the nucleus 
blue and the granules red. 

Degenerations Occurring in the Corium. — Hyaline degeneration 
similar to that occurring in epithelial cells in carcinoma is found also 
in the corium in sarcoma, in rhinoscleroma, in syphilis, and in other 

1 For full consideration of the cells of chronic inflammation, including plasma-cells 
and mast cells, the reader is referred to a critical review of the literature by Williams. 
Amer. .lour. Med. Sei., 1900, cxix, p. 702; a series of papers l>y Pappenheim, ami l>y 
Altakvist, Monatslieite, 1901 2; Maximow'a monograph, Ziegler's Beitrage, Suppl. v. 

L902; ami a iv\ ieu of the subject by Whitfield, Brit. Jour. Derm., 1001. \\ i. pp. 7 and 63. 

'Johns Hopkins Hosp. Hull., 1896, \ii, \>. 110. 



76 GENERAL PATHOLOGY 

affections. It produces a homogeneous material in the cellular proto- 
plasm, which is acidophilic in reaction, and, owing to its semifluid 
character, forms round globules. Ilyalin is stained orange-red by 
Van Gieson's method. 

Fatty degeneration occurs in several conditions in the skin, and is 
well represented in xanthoma. Here arc found variously sized granules 
within a large cell, known as the xanthoma cell, which is characteristic 
histologically of the disease. This cell is the product of a connective- 
tissue cell in the multiplex varieties, while, according to Pollitzer, 1 
in xanthelasma it results from degeneration of muscular tissue. 

Mucoid degeneration is found in the " Mikulicz cells" of rhinoscleroma 
and in the lepra-cells of lepra. In both it occurs as a homogeneous 
mass, within which the specific bacilli are found. 

Edematous degeneration occurs in the cells of the corinm, which is 
the seat of marked edema. They appear swollen, stain poorly, and 
contain fluid. This form of degeneration i- seen in tissue reacting 
after exposure to actinic and Rontgen rays. 

Crenation degeneration is found in granuloma fnngoides, and is evi- 
denced by the cell becoming irregular and toothed. Eventually, the 
cell entirely disintegrates. 

In addition to the cellular degenerations described above, several 
degenerative processes occur which affecl the collagen and elastin. 

Myxomatous degeneration, in which a peculiar jelly-like substance 
containing mucin results from collagenous degeneration, is found in 
sarcoma and myxedema. This substance is basophilic in reaction and 
is stained by any of the metachromatic dyes. 

Colloid degeneration in the skin is comparatively rare. It occurs 
in the disease termed colloid milium. It consists of a homogeneous 
degeneration of the fibrous elements of the corinm. The exact chem- 
ical composition of the colloid material is not known. It is stained 
yellowish-red by Van Gieson's method. 

Other degenerations occur in the corium, in which collagen and 
elastin are concerned, and these are demonstrated chiefly by the 
staining methods described by Unna, 2 and are termed basophilic 
collagen, collastin, collacin, and elascin. 

1 Jour. Cut. Dis., 1S97, xv, p. 367; X. Y. Med. Jour., 1897, Ixv, p. 679. 

2 Monatshefte, 1894, xix, p. 465. 



V. GENERAL DIAGNOSIS. 



The establishment of an accurate' diagnosis in cutaneous dis< 

is essential to their successful management. This statement is ren- 
dered necessary in this connection by the prevalence of a belief among 
the uneducated that the disorders of the skin, exhibited for the most 
part in visible symptoms, can safely be treated on general principles 
without a recognition of the nature of the malady. By many prac- 
titioners the demand for an accurate diagnosis is ignored in conse- 
quence of a too general impression that the desired end is to be 
pursued through great and perplexing obscurity. Yet with patience, 
met hod, a habit of careful observation (without which no physician 
i> successful), and a reasonable degree of skill, both practitioner and 
student can, in the large proportion of all cases, attain their purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of an affected portion of the integument to the 
eye of him who is consulted with a view to its relief. The physician 
is supposed to inspect this surface attentively for a few moments, and 
then to pronounce definitely upon the nature of the disease present 
and the therapeutic measures to be adopted. While such a procedure 
is possible to the expert in a limited number of cutaneous disorders, in 
a large number of cases far more than this is requisite, and, indeed, 
is fully as essential here as in the investigation of disease involving 
any other organ of the body. 

It is true that erythema, urticaria, dermatitis, eczema, purpura, 
alopecia, and many other affections of the skin may often be recog- 
nized after simple and brief inspection of the region involved; but the 
cause of such disorders and their relation to the general health of the 
patient, all of which knowledge is essential to their proper treatment, 
can be obtained only after a much more thorough examination. As 
a pule, it is desirable, first, to secure a history of the physical and 
mental condition of the patient in the past; then should follow the 
special history of the disorders of the skin; lastly, an examination of 
the patient and of the affected integument. The family history may 
be of value in making a diagnosis. For the purpose of methodically 
arriving at these facts, and of preserving them for future reference, 
they should systematically be recorded. The following arc some of 
the points upon which it will generally be found useful to secure infor- 
mation: 

The name, residence, age, sex, occupation, and married or unmar- 
ried state of the patient should be known, as also, whenever prac- 

77 



78 GENERAL DIAGNOSIS 

ticable, the health-history of parents and children. In the ease of 
women, it is not only necessary to learn the history of the menstrual 
function in the past, but it is of the highest importance to he informed 
also as to the previous occurrence of abortions and miscarriages, and, 
if such have occurred, the order observed by these with relation to the 
birth of viable infants. The history of the products of conception has 
a most important bearing upon the question of syphilitic infection. 
The absolute exclusion of syphilis in any obscure 1 case is a long step 
in the direction of an accurate diagnosis. In the instance of male 
patients, questions will usually elicit either admission or denial of 
the fact of a precedent or present venereal disease, and the answers 
should be regarded as valueless or trustworthy according as they are 
or are not substantiated by corroborative clinical facts. 

Then should follow sonic record of the habits of the patient, as to 
active or sedentary employment, bathing, food, and drink, including 
under the latter term the use of beer, wine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear, and the dates of occurrence, recurrence, and 
convalescence be at least approximately discovered. The patient 
should also make known whether he has had refreshing sleep; whether 
he has undergone mental anxieties (domestic, financial, etc.); whether 
he has suffered in his digestive, respiratory, circulatory, genito-urinary, 
or nervous system. Defects in elimination, assimilation, and nutri- 
tion should be noted; and when the symptoms suggest disease of other 
organs than the skin the patient should be subjected to the proper 
physical examination. 

This much ascertained, the patient should be encouraged to nar- 
rate as succinctly as possible, and as far as may be in his own terms, 
the history of the present cutaneous disorder. A systematic series of 
questions put by the examiner should disclose, if possible: the cause 
of the disorder; its appearance when first seen, and any changes in 
character and type which have since occurred; the regions of the 
body affected, in order of involvement; the method of extension, by 
peripheral enlargement of the early areas, or by the appearance of 
new lesions at a distance fiom those first observed; the rapidity and 
regularity of the progress of the disease and its duration; the subjective 
sensations; and the influence of seasons and temperature upon the dis- 
order. The treatment to which the disease has been subjected should 
then be detailed, this frequently furnishing a key to the diagnosis 
and therapy of the malady. In a large proportion of all cases, ignor- 
antly directed and vicious internal or external medication has either 
begotten or aggravated the disease of the skin. This much ascer- 
tained, the physician is ready to examine the affected surface for 
himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful infor- 
mation of which the patient is totally unconscious. Much of this is 



GENERAL DIAGNOSIS 79 

difficult to describe, as it is the rich fruit <»(' wide experience and care- 
ful scrutiny. With a gentle, courteous, and sympathizing manner the 
diagnostician must combine the art of a detective and tin- ^kill of ;i 
swordsman. Glancing occasionally at the face of his patient while 
making record of the answers given, he will, of course, have observed 
any eruption upon that portion of the body. lie will have made a 
mental note of the temperament of the sufferer, and of any movement 
made 1 by the latter indicating a tendency to scratch or nil) portions 
of the skin. He will have noticed the posture, clothing, and head- 
apparel; the existence of hair on the scalp or extensive baldness; the 
condition of the exposed hands, as indicating manual labor or the 
reverse; and, in the absence of facial lesions, will have observed the 
special tint of the skin of the face, as suggesting anemia, chlorosis, or 
a general condition of cachexia. The facial expression, as indicative 
of anxiety or placidity, habits of debauch, sexual excesses, etc., will 
not have escaped his attention. All this and much more will possibly 
have enabled the questioner to direct his interrogatories into the 
channel in which they will elicit the most useful responses. The 
posture, cries, facial expression, and general condition of nutrition of 
the infant will have been no less carefully noted. 

Proceeding to the examination of the affected integument, the 
physician must assure himself of a good light, as colors are best dis- 
tinguished by daylight and artificial illumination should be reserved 
for exploration of the cavities of the body. The air of the apartment 
should be sufficiently warm to permit of exposure of the person with- 
out discomfort and without causing disturbance of the cutaneous cir- 
culation. Adult males and children of both sexes should have the 
clothing completely removed so that all portions of the skin may be 
inspected. One portion of the body may, however, be examined, and 
then covered if desired, while the examiner proceeds to direct his 
attention to another part. In the case of women the investigation 
should be conducted with the tact and delicacy to which the sex is 
entitled. 

The examination, whenever practicable, should extend over the 
entire surface of the integument. The importance of this point can 
scarcely be exaggerated. It must be remembered that the physician 
should be much wiser than his patient, and the assurances of the 
latter are always to be accepted with reserve. r l nus, one who merely 
exposes his leg, stating that this is the only part of his body affected, 
may have concealed beneath his clothing extensive varicosities of the 
veins of the thigh, a typical syphilitic exanthem over the abdomen, a 
significant scar on the elbow, an extensive patch of tinea versicolor on 
the surface of the chest, or a blennorrhagic discharge from the urethra, 
the medication of which has induced the rash for which he seeks 
relief. These are not the rare, but are the common, cases of a dailj 
experience. 

Observation should be had at this time of the general and special 
features of the eruption. As to the former, the following consider;! 
tions should be borne in mind : 



SO GENERAL DIAGNOSIS 

The original manifestations of a cutaneous disease may be masked 
or entirely hidden by the lesions resulting from scratching, or by a 
dermatitis due to loeal applications, or to drugs taken for the relief 
of the original disorder. It is of the greatest importance that the 
accidental nature of these symptoms he recognized, as they otherwise 
lead to great confusion in diagnosis. 

Rarely a disease involves the entire surface of the body, leaving 
no part unaffected, and then is said to he universal in distribution; 
more frequently an eruption affects at one time several or most of 
the regions of the body-surface, and then is called generalized; much 
more commonly an eruption affects a considerable portion of hut 
one or several regions, and is said to he diffuse; or it is limited to small 
areas of one or several definite regions, and is known as a local eruption. 

A symmetrical eruption, one equally distributed over correspond- 
ing regions of both sides of the body, is rarely the result of an etio- 
logical factor operating upon the outer skin. It more often points to 
an efficient cause of internal origin. An eruption affecting the cov- 
ered integument, never creeping out upon the exposed surfaces, sug- 
gests the operation of the clothing, as the latter may chance to prove 
the nidus or protector of a parasite, the fabric which has been colored 
by a noxious dye, the recipient of a chemically altered secretion which 
has proved irritating to the surface* the instrument of friction, or the 
source of increased temperature at the surface by its non-conductivity 
of heat and unseasonable thickness. An eruption accompanied by 
excoriations and scratch-lino i> usually severest in the parts most 
accessible to the hands, and least developed where the latter have 
the least play, as over some parts of the back. An eruption limited 
to the hands is likely to be one induced by an agent to which the 
hands alone have been exposed. Such are the eruptions originating 
in the trades and domestic occupations; in the latter, an eruption 
more distinct on the right hand, and especially about the right thumb 
[ind index finger, tells its own story when the handworker is not 
ambidextrous nor left-handed. Artificially and intentionally produced 
eruptions, as in malingering, hysteria, mental depravity, and insanity, 
usually occur also in parts to which the right hand finds easy access. 

Eruptions occurring on the face, the hands, and the genitalia of men, 
or on the face, hands, and mamma? of women, point to external con- 
tact or contagion (poison-ivy, scabies, croton-oil, etc.), since, next 
to the face, the hands are more commonly brought in contact w r ith the 
parts named in the sexes respectively, as the wearing-apparel of each 
suggests. 

An eruption limited to the forehead suggests an inspection of the 
hat-band, the veil, or the overlying false hair; to the ears of women, 
a glimpse at possibly cheap ear-rings; to the centre of the root of the 
neck, before or behind, a scrutiny of the collar-button and collar; to 
the anus of the baby, an inquiry as to the changing of its napkins; to 
the wrists of the adult, a question as to the cuffs w T orn; to the feet, 
information respecting gaiters, varicose veins, recently cut corns, and 



',/ \ ERAL DIAGNOSIS 81 

Ill-fitting hoots. Eruptions springing From each of these cau es have 

been treated long and vainly as "diseases of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetric- 
ally operating causes thai is, the accidents of environment, or else 
influences exerted within the body unequally on its two lateral halves. 

Thus, an orthopedic apparatus worn to correct talipes excites a der- 
matitis of the leg of the affected side only; and zoster of the trunk is 
evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphil- 
ides, the quinin-exanthem, rubeola, and even lupus erythematosus, 
are remarkable illustrations of this fact. 

Proceeding' with the visible characteristics of the disorder, the 
physician will not. fail to note an acuteness or chronieity of the erup- 
tion; also, the presence or absence of an exudate on the surface. 

After obtaining an impression of the general features of an erup- 
tion the individual lesions should be carefully studied. The type of 
lesion (papule, tubercle, vesicle, etc.) should be noted. When the 
lesions are multiform the different types should be examined to de- 
termine, if possible, which are primary and which consecutive in appear- 
ance; which are essential and which accidental in the process. For 
the purpose of studying the characteristics of the individual lesions, 
those of most recent appearance (usually at the border of a patch), 
and as yet unmodified by scratching, treatment, and other influences, 
should be selected. Often, however, the full evolution of a lesion 
requires time, and its successive stages should be determined by 
observing a number of lesions of different ages. 

The arrangement of lesions varies greatly in different diseases. 
When grouped such lesions may develop in circular, oval, angular, or 
irregular-shaped areas; or in circinate, gyrate, serpiginous, straight, or 
irregular bands and lines. In some affections (as ringworm, psoriasis, 
syphilis) the areas may become clear in the centre as the border pro- 
gresses. Lesions may be grouped, and yet be discrete in that each 
lesion preserves its outline and identity; or they may coalesce so 
completely that all trace of the form of the individual lesion is lost. 

The definition of lesions is another important diagnostic feature 
in which cutaneous affections vary greatly: the line dividing the dis- 
eased from the normal skin may be so sharp and fine that it can be 
traced with the point of a pin; or the lesion may shade so gradually 
into the normal skin that its outline cannot be definitely determined, 
and it is said to have poor definition or none. 

The color of lesions of the skin often depends greatly upon circum- 
stances having no bearing upon the disease in question. It thus varies 
with the natural color (light or dark) of the individual's skin, with 
the temperature of the surface, and with the amount of irritation to 
which the surface has been subjected by friction with rough clothing, 
scratching, treatment, etc. There are, however, some diseases (syphilis, 
G 



82 GENERAL DIAGNOSIS 

lichen planus, tinea versicolor, favus, and others) in which the color 
may be of great importance in the diagnosis, and there are many 
maladies in which consideration of this characteristic of the eruption 
is of value if the accidental modifications be borne in mind. The 
acuteness or chronicity of a disease is often indicated by the color of 
the lesions. The persistence, modification, or disappearance of color 
under pressure should be noted. For this purpose a small glass disk 
or glass tongue-depressor (diascope) is better than the finger. 

In judging of the size of a lesion it is sometimes important to learn, 
by palpation, how much of it is above the general surface of the skin 
and how much is more deeply situated. In noting the shape of papules, 
tubercles, vesicles, and pustules, both apex and base should be taken 
into consideration. Thus, the apex may be pointed (acuminate), 
rounded (obtuse), flat (plane), or depressed (umbilicated). The base 
may be round, oval, angular, polygonal, or irregular. 

The situation of lesions in or about the hair-follicles or at the open- 
ing of the ducts of the sebaceous or coil-glands is a diagnostic point 
of great value. It is important to know if certain lesions appeared 
first upon normal skin, or if they originated in other lesions. Thus, 
vesicles and pustules may arise from sound surfaces, or from the 
apices of papules or tubercles. The majority of even the elementary 
lesions are probably preceded by macules, which, however, are often 
so transitory as to be unrecognized and unimportant. 

The career of an individual lesion, which often bears no relation 
to the duration of the disease as a whole, should be noted. Thus, the 
vesicle of eczema rarely exists as such for more than a few- hours, 
though by the formation of new vesicles eczema may persist for months; 
while in zoster, individual vesicles last several days, though the dis- 
ease as a whole is short-lived. In some diseases the type of lesion 
remains the same throughout its career unless modified by treat- 
ment or external influences, while in others the type changes or is 
complicated by other types. Thus, the papule may be modified by 
developing at its apex a vesicle or pustule. The career of lesions can 
usually be studied, not only by watching them from day to day, but 
also — and more easily — by observing at one time a number of lesions 
in various stages of development. 

As the lesions of different affections vary greatly in their evolu- 
tion and career, so do they in their involution. While in the majority 
of instances it is the recent and newly formed lesion that is most 
useful for purposes of study, there is often much to be learned from 
the manner in which lesions disappear and in the traces they leave. 
The papule or tubercle which ulcerates usually suggests (aside from 
some rare disease) syphilis, tuberculosis, or carcinoma, and may be 
sufficient to exclude from the diagnosis the possibility of psoriasis, 
seborrhea, and other superficial affections. In a doubtful case, the 
termination of some of the lesions in scar-tissue may be the one fact 
needed to make a differential diagnosis between seborrhea and lupus 
erythematosus, or between a circinate form of psoriasis and a similar 



GENERAL DIAGNOSIS 83 

type of syphilitic eruption. Pigmentation sufficiently character] tic 
for a diagnosis is left after the otherwise complete involution of ome 
lesions. This is most frequently true in zoster, lichen planus, and some 
forms of syphilitic eruptions. In estimating the time of involution 
of lesions and in making a prognosis regarding the disappearance of 
pigmentation (a point upon which patients are often solicitous), it 
should be remembered that pigment is usually removed very slowly 
from the lower extremities and other dependent portions of the body, 
and that in such localities it may persist for months or years after it 
has disappeared from parts in which the return-circulation is better. 

Certain lesions have special features that should he studied. These 
are given in detail in the last division of the outline at the close of 
this chapter. 

Before concluding his examination the physician will rupture a 
bleb, pustule, or vesicle, should such be found, to discover the nature 
of its contents. He will remove one or several crusts in sight, to 
expose the surface on which they rest. He will scrape away a few 
scales with the dermal curette for a similar reason. He will pinch 
between thumb and finger a portion of each part, in order to deter- 
mine its infiltrated condition, its atrophy, or its attachment to the 
tissue beneath. He will pass his hands over the surface to recognize 
the firmness or the softness of the lesions, their inflammatory, hyper- 
plastic, or neoplastic character, their dryness or moisture, and the 
existence of sebaceous or of perspiratory secretion. He will look at 
the mouths of the follicles where such secretion is retained or is abun- 
dantly exuded. He will discover any lice or their ova between or 
upon the hairs, any ascarides about the anus, any morbid forma- 
tion of the nail or deformity of its matrix. He will examine for inguinal, 
post-cervical, axillary, and epitrochlear adenopathy, and will thus 
be often greatly aided in his task. A physical examination of the 
internal organs is often demanded. The mucous membrane of the 
mouth and throat frequently exhibits signs of past or present disease. 
Careful inspection should therefore be made of the tongue, the gums, 
the inside of the lips, the fauces, and the tonsils. A mucous patch here 
will often echo the story of a palmar or a plantar syphiloderm. The 
laryngoscope may be called for in syphilis, cancer, lupus, and leprosy. 
The degree of distention of the abdomen and the region of hepatic 
dullness should not be overlooked. The genitalia of men and of 
children and infants can usually be explored. For women unaffected 
with syphilis or disease limited to these parts an exception in this 
particular should usually be made. 

In many cases the microscopical and bacteriological examination 
of hairs, scales, crusts, exudate, or tissue is essential to the diagnosis. 

With the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
Jitter the manner described above is in possession of the diagnosis tor 
which he seeks. If the facts thus acquired have properly been re- 
corded, and yet do not spell out such a diagnosis to his eyes, thc\ will 



84 GENERAL DIAGNOSIS 

probably be legible to others with a wider experience or riper judg- 
ment, to whom such a record may be shown. It is not claimed that 
this exhaustive method of examination is requisite in every case, as, 
for example, in order to recognize favus or to differentiate erysipelas 
from erythema. But it is certain that few obscure cases of skin dis- 
ease will remain such under severe scrutiny, and the establishment of 
a thorough and exhaustive method of examination is important in the 
earliest experience with disease. Let the student or the practitioner 
conduct such an examination in the first few cases of eruption upon 
the surface of the body for which his advice is sought, and he will 
establish a habit of observation in comparison with which his pecuniary 
or professional success in the management of the same cases will 
indeed be of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of ;i diagnosis which is not 
based upon such an examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the verdict of even skilled 
practitioners may be founded upon an error. The careful diagnos- 
tician should begin hi-- task in a spirit of skepticism, and pronounce 
definitely only upon ascertained facts. The man who says he has an 
"eczema" may be louse-bitten; the woman who has been "overheated" 
may prove syphilitic. The patient recognized as suffering from ring- 
worm of the beard may not have been infected under the hands of a 
barber. Finally, the eruptions upon patients unmistakably syphilitic 
are often of other than syphilitic origin. These infected subjects — 
men, women, and children — an- exposed daily to the accidents from 
which the non-infected stiller. They exhibit acne, physiological 
alopecia, and dermatitis medicamentosa equally with the non-syphilitic. 

Tuberculin. — Three methods of administering tuberculin for pur- 
poses of diagnosis are now available: first, by giving lrvpodermat- 
ically Koch's old tuberculin; second, the "von Pirquet" tuberculin 
test; and third, the ophthalmo-tubereulin test. 

Hypodermic Test. — Koch's old tuberculin is given preferably at 
midnight, beginning with one-quarter of a milligram (0.00025). The 
patient should have been prepared by being kept quiet for two days 
preceding the test and his temperature taken every two hours to 
determine the normal. If this be found to amount to 100 or more 
degrees the test should not be used. The reaction begins in from 
eight to twenty hours after the injection, usually in eighteen hours, 
and is indicated by a rise in temperature to 100, 101, or even 104 or 
105 degrees. This is accompanied by severe headache, a feeling of 
general malaise, pain in the back and limbs, loss of appetite, at times 
nausea and vomiting, and, if severe, by grave prostration. As a rule, 
the symptoms subside in twenty-four hours, but may require two or 
three days to disappear. In addition to the general symptoms above 
recorded a local reaction is evident in the cutaneous lesion, exhibited 
by redness and other inflammatory phenomena. If no reaction' occurs, 
a second dose of one milligram (0.001) is given in three days. If still 



SERUM DIAGNOSIS OF SYPHILIS 85 

do reaction, a third dose of three milligrams (0.003) is given in another 
three days. 1 1' after t his do reaction is evident, the diagnosis may be 
considered Degative as to tuberculosis. 

"Von Pirquet" Test. This is practically a local vaccination method. 
Two solutions are necessary: first, a 25 per cent, solution of Etoch/s 
old tuberculin; second, a blank solution. Dr. Lincoln 1 suggests for 
the first solution one part tuberculin, one part 5 per cent, phenol 
in glycerin, and two parts sterile 0.85 per cent, salt solution. The 
blank solution represents one part 5 per cent, phenol in glycerin and 
three parts sterile 0.85 per cent, salt solution. 

The arm is cleansed as in ordinary vaccination and one drop of 
each of the above solutions is placed on the cleansed area about two 
inches apart. Each is then scarified into the skin, with care not 
to make the surface bleed. Each drop is allowed to dry and is pro- 
tected by a shield. In twenty to twenty-four hours the reaction, if 
it occur, is at its maximum and is exhibited as a hyperemic, sharply 
circumscribed, infiltrated lesion. There may be vesicle-formation, 
followed by crusting. In the area treated by the blank solution no 
significant change should occur. The reaction subsides in one to 
three weeks and is unaccompanied by constitutional symptoms. 

Ophthalmo-Tuberculin Test. — A 1 per cent, solution of tuberculin 
is used. This may be prepared by adding one tablet of prepared 
tuberculin (to be had in the market, prepared for this purpose) to 
1 c.c. of sterile 0.85 per cent, salt solution. 

The eyes should be free from all evidence of inflammatory changes 
when the test is made. If found normal, one drop of the solution 
named is instilled into one eye. The liquid should be moderately warm 
and then evenly diffused over the conjunctiva by gentle manipula- 
tion of the lower lid. The reaction reaches its maximum in twenty- 
four to thirty-six hours and subsides in two days to one week, as a rule, 
and is exhibited as a catarrhal conjunctivitis. Usually no subjec- 
tive sensations are present, though mild burning and smarting with 
photophobia may occur. 

A positive reaction is indicative of tuberculosis in some region of 
the body, provided the eye has not been previously tested. It is 
important to note that tests repeated after five or eight days are 
valueless. 

Serum Diagnosis of Syphilis (Wassermann Reaction). 2 — The 
complement-fixation test, as employed in syphilis, was first used by 
Wassermann, Xeisser and Bruck. 3 Its elaboration was math' pos- 
sible by the principles involved in the Bordet and Gengou reaction. 1 
This reaction, with the principles of hemolysis, must be understood to 

1 Lincoln, May C, Jour. Amcr. Med. Assoc, L908, vol. li, L> 1 , 1 756- 1 7<i 1 . 

'-' Fleischmann and Butler, Jour. Amcr. Med. Assoc., 1907, xlix, p. 924; Butler, \<u 
N ork Med. Jour., Nbvembei •':<>, 1907; idem., Jour. Amer. Med. Assoc, L910, liv, p. 1 1 1 l : 
Howard Fox, Med. Record, V« York, March L3, L909; Swift, Archives of Enternal 
Med., 1909, iv, p. :>7f> (A Comparative Study of Serum Diagnosis in Syphilis). 

■ Deutsch. med. Wochenschr., L906, \i\, p. 745. 

' Annales de ['Institute Pasteur, 1901, p. 289. 



86 GENERAL DIAGNOSIS 

appreciate the phenomena occurring in the test as applied to syphilis. 
Special laboratory facilities are required and much experience is neces- 
sary to make the test reliable. Many factors are concerned and 
much time is required, which make its performance purely a labora- 
tory function. To obviate some of the disadvantages, many modi- 
fications have been used, 1 but the major portion of workers employ 
the so-called original test rather than its modifications. Boas- uses 
a quantitative method, by which more accurate results are obtained. 
Five amounts of serum, ranging from 0.2 c.c. to 0.01 c.c, are used, 
and in addition practically all workers agree that more than one antigen 
should be employed. 3 The principles and application of the test were 
early brought out in America by Meisclunann, Butler, Howard Fox, 
Noguchi, and others. The technique as employed by Dr. .1. Frank 
Waugh is briefly outlined by him as follows (Cf. chapter on Diagnosis 
of Syphilis for discussion of practical value of test). 

Five factors are wmh\ in performing the test: sheep's corpuscles, 
amboceptor, complement, antigen, and patient's scrum. 

The first known factor to be prepared Is a 5 per cent, suspension of 
washed sheep's corpuscles. The sheep's blood is defibrinated as soon 
as withdrawn from the animal and is then stored in an icebox until 
the test i^ to be made. Corpuscles over forty-eight hours old should 
not be used. The amount of defibrinated sheep's blood used de- 
pends on the number of sera to be tested. One c.c, after being 
washed at least twice in nonnal-sdt solution, added to 19 c.c. nor- 
mal-salt solution, will make 20 c.c. of a 5 per cent, suspension, as 
the normal defibrinated sheep's blood is considered a 100 per cent. 
suspension. 

The next step is to determine the titre of the amboceptor con- 
tained in the inactivated serum of a rabbit immunized against sheep 
corpuscles by the successive intraperitoneal injections of washed 
sheep's corpuscles. Usually five injections of 2 c.c, 5 c.c, 8 c.c, 12 
c.c, and 15 c.c, respectively, at five-day intervals, will suffice, the 
animal being bled nine days after the last injection. 

Into each of a series of test-tubes is placed 1 c.c. of the 5 per cent, 
suspension of sheep's corpuscles and variable amounts of the inacti- 
vated rabbit serum; an equal and sufficient amount of complement 
or fresh guinea-pig serum being added to each tube, in order that all 
the amboceptor present be utilized in the process of hemolysis. From 
0.10 to 0.12 c.c of guinea-pig serum is used in each tube in titrating the 
amboceptor. The tube in which hemolysis is just complete contains 
1 unit amboceptor. By reversing the process, or placing 1 unit ambo- 

1 Noguchi, Jour. Exper. Med., 1909, ii, p. 392 (A New and Simple Method for the 
Serum Diagnosis of Syphilis); Waugh, Trans. Amer. Med. Assoc., Sec. on Derm., 1910, 
p. 193 (Results of Experience with Noguchi Modification of the Wassermann Sero- 
diagnosis Test for Syphilis); Howard Fox, Jour. Cut. Dis., 1909, xxvii, p. 338. 

2 Die Wassermannsche Reaktion mit besonderer Beriicksichtigung ihrer klinischen 
Verwertbarkeit (Harald Boas, Berlin, 1911, German translation); discussed by Fildes, 
Brit. Jour. Derm., 1911, xxiii, p. 13 (The Wassermann Reaction). 

3 Stillians, Jour. Cut. Dis., 1913, xxxi, p. 316. 



SERUM DIAGNOSIS OF SYPHILIS 87 

eeptor in each tube and variable amounts of complement, the titre 
of the complement is determined. Two units of each are used in the 
test. One C.C. of sheep's corpuscles, I unit amboceptor, and I unit 
complement constitute the hemolytic circle. When all are added 
to one tube, complete hemolysis results. 

A Dumber of antigens have been recommended by different serolo- 
ui-t-. The following preparations have proven to he the most satis- 
factory: an alcoholic extract of a luetic fetal liver, using Porges 
and Meier's 1 method of preparation; alcoholic extracts of normal 
organs, a human or beef heart or liver usually being used and pre- 
pared by Michaelis and Lesser's 2 method; a cholesterinized alcoholic 
heart or liver extract, as recommended by Sachs; 3 and an acetone, 
insoluble antigen composed of lipoids from a beef liver, as advocated 
by Noguchi. 4 After having been prepared, the antigenic properties 
of the different antigens are determined by careful titration, using 
both luetic and normal serum. 

It should be the rule that the amount of antigen selected as a unit 
should be the amount which does not bind complement, even when 
the antigen is used in double quantity, which does not cause hemolysis, 
and which does not inhibit hemolysis when normal serum is used. 
One unit of antigen is used in the test. 

The patient's serum is secured by withdrawing blood from a vein, 
permitting it to clot, and inactivating the serum at 50° C. for half an 
hour in a water-bath. Washed sheep's corpuscles as recommended by 
Jacobeaus are then added to the serum, which is placed in an incubator 
for thirty minutes, during which period the normal anti-sheep ambo- 
ceptor, if present, will be taken up by the corpuscles. The serum 
is then eentrifuged, pipetted off, and placed in the icebox. From 
0.1 c.c. to 0.2 c.c. is used in the test. 

All the material for the test having been prepared, test-tubes are 
cumbered and placed in a suitable rack or holder. There should be 
at least five for each serum. Others can be added if desired, in which 
may be placed additional antigens, if more than two are used, or 
variable amounts of the serum to be tested, if more than two different 
quantities are desired. 

In the first five test-tubes are placed 2 units of complement; in 
tubes one and three, 0.1 c.c. of the serum to be tested; in tubes two, 
four, and five, 0.2 c.c. of the same serum. In tubes one and two, 1 
unit of antigen Xo. 1, and in tubes three and four 1 unit of antigen 
No. 2 is added. In the second group of five tubes a similar distribu- 
tion of the ingredients is made, using positive luetic serum in place 
of the unknown. In the third group normal serum is placed as above 
described, the antigens and the complement being the same as in the 

' Berlin, klin. Wochehschr., 1908, xlv, p. 731. 

1 [bid., 1908, xlv, p. 301. > [bid., 1911, xlviii, p. 2066. 

' Serum Diagnosis <>f Syphilis. II. Noguchi, 3d edit ion. 



88 GENERAL DIAGNOSIS 

first two groups. Additional control tubes contain double the amount 
of antigens used in the test, with 2 units of complement. 

The tubes are shaken to insure thorough mixing, then incubated 
for one hour. One c.c. of the 5 per cent, corpuscle suspension] 
1 c.c. of normal-salt solution, and 2 units of amboceptor are then 
added to all tubes and the tubes again placed in the incubator. 
Hemolysis is usually complete within an hour in all tubes except 
those containing luetic serum and to which antigen was added; in 
these the corpuscles remain in suspension, which indicates a positive 
reaction. The final reading is taken several hours after the second 
incubation. The test is one of degree, depending upon complete or 
partial inhibition of hemolysis. 

Luetin Test. 1 — In Hill, Noguchi introduced another diagnostic test 
for syphilis, consisting of a cutaneous reaction similar to that devised 
by von Pirquet for tuberculosis. The material \\^vi\ in the test is 
termed " luetin," and is prepared by Noguchi as follows: 

'Tine cultures of several strains of the pallidum are allowed to 
grow for periods of six, twelve, twenty-four, and fifty days at 37° C, 
under anaerobic conditions. One set is cultivated in ascitic fluid 
containing a piece of sterile placenta, and the other in ascitic-fluid agar 
also containing placenta. The lower portion of each solid culture, in 
which a dense growth has occurred , is cut out and the tissue removed. 
The agar columns, which contain innumerable spirochetal, are then 
carefully ground in a sterile mortar. The resulting thick paste is 
gradually diluted by adding, little by little, the fluid culture, which 
also contains an enormous ma>s of the pure organisms. 

"The dilution is continued until the emulsion becomes perfectly 
liquid. The preparation is next heated to 00° C. for thirty minutes 
in a water-bath and then 0.5 per cent, tricresol is added. When 
examined under the dark-field microscope, numerous dead pallida per 
field may be seen. Cultures made from this suspension remain sterile 
and with it no infection can be produced in the testicles of rabbits. 
The suspension is kept in a refrigerator when not in use. 

"In order to ascertain whether the reaction with this suspension 
may not be due to the introduction of antiseptic culture medium 
alone, it is necessary to prepare a similar emulsion, with uninoculated 
media, to be used for control purposes." 

Technique of Application. — Xoguchi recommends the injection of 
luetin in one arm, with the control material in the opposite arm. 
Several others have used both injections in the same arm. In either 
case, the proposed sites for inoculation are thoroughly cleansed in the 
manner ordinarily used in the preparation for a surgical operation. 
The luetin and the control emulsions are thoroughly shaken and the 
desired amounts of each are removed from the containers with sterile 
pipettes and diluted with an equal quantity of sterile salt solution. 

1 Noguchi, Jour. Exper. Med., 1911, xiv, p. 557: "A Cutaneous Reaction in Syphilis." 
Idem., Jour. Amer. Med. Assoc, 1912, lviii, p. 1163. 



LUETIN TEST 
They arc then placed iii sterile graduated tuberculin yringe fitted 

with fine needles. An hit radermic injection, consisting of 0.1)7 C.C. 
of h let ill, is made in one area and a similar (plant it y of eon t rol material 
injected in the other. It is recommended always to make the injec- 
tion as superficial as possible. 

The reactions which follow are described by Noguchi as follow-: 

Normal <>r Negative Reactions. — In the majority of normal persons, 
there appears after twenty-four hours a small erythematous area ;it 
and around the point of injection, unaccompanied by subjective sen- 
sations. The reaction gradually recedes within forty-eight hours 
and leaves no induration. In occasional instances a slight yellowish 
pigmentation results from mild ecchymosis. 

Positive Reactions. — Three forms are described: (1) A papular 
form, in which a large, raised, reddish, indurated papule, usually from 
5 to 10 mm. in diameter, makes its appearance in twenty-four to 
forty-eight hours. The papule may be surrounded by a diffuse zone 
of redness and show marked telangiectasis. The dimensions and the 
degree of induration slowly increase during the following three or four 
days, after which the inflammatory processes begin to recede, and the 
color of the papule gradually becomes dark bluish-red. The induration 
disappears within one week, except in certain instances, in which a 
trace of reaction may persist for a longer period. (2) A pustular form, 
the beginning and course of which resemble those of the papular 
form until about the fourth day, when the inflammatory processes 
commence to progress. The surface of the indurated, round papule 
becomes mildly edematous, and multiple miliary vesicles occasionally 
form. At the same time a beginning central softening of the papule 
can be seen. Within the next twenty-four hours the papule changes 
into a vesicle, filled at first with a semiopaque serum, which later 
becomes definitely purulent. Shortly afterward the pustule rup- 
tures; its margin remains indurated, and its surface becomes covered 
with a crust, which falls within a few days. With the fall of the crust 
the induration disappears, leaving no sequels. A wide range of vari- 
ation in the degree of intensity of the reaction described in different 
cases has been noted. (3) A torpid form. In rare instances the 
injection sites fade away to almost invisible points within three or four 
days, so that they may be passed over as negative reactions. These 
spots suddenly light up again after ten days or even longer and pro- 
gress to small pustular formations, the subsequent course of which i> 
similar to that described above. 

The papule above described is in most instances a comparatively 
deep-seated, inflammatory nodule, and is frequently surrounded by a 
bright-red areola, varying from half an inch or lc>s to two or more 
inches in diameter. Constitutional symptoms vary. As a rule, a 
slight rise of temperature is present for one day. With a marked 
reaction, however, general malaise, loss of appetite, and diarrhea may 
occur. 

The test is chiefly of value in chronic cases, being rarely positive 



90 



GENERAL DIAGNOSIS 



during the early and more active stages of the disorder. The reaction 
depends upon the hypersensitiveness induced in the system by the 
long-continued action of the Spirocheta pallida. In the early and active 
stages, where the Wassermann test is of most value, the luetin test is 
of little use; in the later and latent stages of the disease, where the 
Wassermann is liable to be negative and the disease still present, 
the luetin test becomes of value. Noguchi states that when syphilis 
has entered upon its chronic course, the direct demonstration of the 
Spirocheta pallida becomes difficult, if not impossible, the Wassermann 
reaction less frequently positive, and the clinical aspect less decisive. 
Here the detection of the allergic condition by the luetin test will be 
an aid in deciding the diagnosis in doubtful cases. As summed up by 
Foster, 1 a positive Wassermann test indicates the presence of meta- 
bolic substances in the blood serum, due to present or recent, activity 
of numbers of spirocheta' on the tissues; while a positive 1 net in reaction 
is indicative of a state of hypersensitiveness to the specific proteins of 
the spirocheta 1 , induced by a period of cessation of the introduction 
of these proteins prior to the injection of the luetin. 2 

Method of Examination. The following outline for the methodical ex- 
amination of a patient affected with skin disease is based on the subjects 
considered in the preceding pages, and is given in such detail that a care- 
ful investigation of the questions suggested should furnish material for 
all but exceptional cases. I'W the average case much may be omitted. 

The first, attempts to follow such a scheme are necessarily tedious, 
and therefore often discouraging; but one patient thus carefully ex- 
amined is of greater educational value than an aimless and indefinite 
examination of a dozen cases. There is no greater economy of time 
than is found in methodical and systematic habits of work. 



HISTORY. 



I. 

II. 

III. 

IV. 



VI 



VII 
VIII 

IX 



Name and Residence. 
Age. 

Sex. 

Married or Unmarried. 

1. Children. 

a. Living. 

b. Dead. 

2. Abortions or Miscarriages. 
V. Family History. 

Individual History, including 
that of previous skin diseases. 
Occupation. 

Habits of eating, drinking, bath- 
ing, tobacco-usage, etc. 
Present State of Health. 
(Note the condition of the diges- 
tive, respiratory, circulatory, 
genito-urinary , and nervous 
systems; also, defects in as- 
similation, elimination, and 
nutrition.) 



History of Present Skin Dis- 
eases. 

1. Cause — if known. 

2. Character at first. 

3. Sites affected in order. 

4. Manner of progressing. 

a. Slow or rapid. 

b. Steady or irregular. 

c. With exacerbations and 

remissions. 

d. With periods of entire 

freedom from symp- 
toms. 

5. Changes in character. 

6. Subjective sensations. 

7. Duration. 

8. Effect of temperature and 

seasons. 

9. Treatment to date. 



1 Amer. Jour. Med. Sci.. 1913, cxlvi, p. 645. 

2 For further discussion relative to the clinical application of the test, see chapter 
on Syphilis devoted to diagnosis. 



GEh ER I/. h/.\(,\os/s 



91 



OBJECTIVE SYMPTOMS. 



\ \i i mi \ r \i. ( Iomplic ITION8 due to 

scratching, treatment, etc. 
I',. Site. 

1. Universal. 

2. Generalized. 
:;. Diffuse. 

1. Local. (Note influence of 
clothing, occupation, etc.) 

I. Uniformity, or multiformity. 
II. Arrangement. 

1. Isolated. 

2. ( rrouped. (Circulate, lin- 

ear, etc.) 

3. Discrete. 

-I. Coalescing. 
5. Irregular. 

III. Definition. (Sharp, fair, poor, 

or none.) 

IV. Elevation, or depression. 
V. Color. 

1. Persistent. 

2. Changing or disappearing 

under pressure. 
VI. Shape. 

1. Apex. 

2. Base. 
VII. Size. 

1. Superficial. 

2. Deep. 
VIII. Anatomical site. 

C. Symmetry, or asymmetry. 
I). Acuteness, or chronicity. 



E. Moisture, or at,. , ,,< , "/ 
I •'. I \Di\ mi \i, Lesions. 

I Elementary (macule, papule, 
wheal, tain rrt, , tumor, i < icL , 
pa.stalr, or lih b 
2. Consecutive (scale, crust, excori- 
ation, fissure, a In /-, or scar . 

IX. Consistence. 

1. Firm. 

2. Soft. 
X. Base. 

1. Color. 

2. Infiltration. 
XI. Evolution. 

1. From sound skin. 

2. From other lesions. 

XII. Career. 

1. Transitory. 

2. Persistent . 

3. Type. 

a. Simple. 

b. Changing. 

c. Modified. 

XIII. Involution. 

1. Resorption. 

2. Exfoliation. 

3. Ulceration. 

4. Atrophy, etc. 

XIV. Sequelae. 

1. Stains. 

2. Scars. 



SPECIAL FEATURES TO BE OBSERVED IN CERTAIN LESIONS. 



A. Vesicles, Pustules, or Blebs. 
I. Roof. 

1. Tense. 

2. Flaccid. 

3. Easily ruptured. 
II. Contents. 

1. Translucent, or opaque. 

2. Serous. 

.'!. Purulent. 
I. Hemorrhagic. 
III. Surface beneath. 
[V. Areola. 
V. Involution. 

1. Desiccation. 

2. Rupture. 
:;. ( 'rusts. 

B. Scales. 

I. Size. 
II Color. 
HI. Quantity. 
I\ . ( -onsistence. 

1. Dry. 

2. Fatty. 

3. Friable. 
I. Tough. 

V. Attachment. 

1 . Firm. 

2. Slight. 



VI. Surface beneath. 

1. Color. 

2. Dry. 

3. Greasy. 

4. Hemorrhagic. 
C. Crusts. 

I. Size. 
II. Shape. 

III. Color. 

IV. Composition. 

1. Serum. 

2. Pus. 

3. Blood. 
V. Attachment. 

VI. Thickness. 
VII. Consistence. 
VIII. Surface beneath. 

I). Excoriations. 

I. Distribution. 
II. Shape. 

III. Arrangement. 

IV. Relation to other lesions 
X. Exudation. 

E. Fissures. 

I. Distribution. 
II. Size. 

1. Leu-tli 

2. Depth. 



92 



GENERAL DIAGNOSIS 



III. 


Pain. 


IV. 


Moisture. 


F. Ulcers 


I. 


Size. 


II. 


Depth. 


III. 


Contour. 


IV. 


Base. 




1. Soft. 




2. Infiltrated. 




3. Indurated. 


V. 


Edges. 




1. Sloping. 




2. Perpendicular. 




'A. Punched. 




4. [lagged. 




.I. Everted. 




6. Undermined. 




7. Soft. 




s. [ndurated. 


VI. 


Floor. 




1. Smooth. 




2. Uneven. 




:\. Clean. 




1. Pus-covered. 




."). ( rranular. 




ti. Sloughing. 




7. Hemorrhagic. 




s. Glazed. 



VII. 


Secretion. 




1. Scanty. 




2. Pi of use. 




;>. Serous. 




1. Purulent. 




">. Hemorrhagic. 




ti. Odor. 


\ 111. 


Pain. 


IX. 


Crust . 


X. 


Evolution. 


XI. 


Duration. 


XII. 


Involution. 




carefully the number and 




location of ulcers, the age of 




the patient, and the character 




of scars if present.) 


S. \i{s. 


I. 


Size. 


II. 


Shape. 


III. 


( Jolor. 


IV. 


Depression, or elevation. 


V. 


Texture. 




1. Soft, pliable. 




2. Hard, indurated. 




:;. Thin. 




1. Thick. 




."). Smooth. 




(I. Rough, corded. 


VI. 


At tachment. 


VII. 


1 >eformity. 


\ III. 


Subjective sensal ion. 


IX 


Absence or presence of hairs, 




glands, and papilla?. 



VI. GENERAL PROGNOSIS. 



The prognosis of most diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection with skin diseases. 
Many of the latter are trivial, some are grave, a few are inevitably 
fatal in their termination. Thus, general exfoliative dermatitis, lep- 
rosy, sarcoma, carcinoma, at times lichen ruber, and variola in the 
unprotected are of grave portent; while the ordinary congestions and 
exudations, the great majority of all cases of acquired syphilis in 
adults, and the entirely curable diseases induced by parasites do not 
exeite alarm in the breast of the average patient with respect to his 
longevity. 

The questions, however, as to his future, which are urgently pressed 
by the victim of cutaneous disease, are both numerous and impor- 
tant. He is anxious as to the time during which he must suffer; as 
to the possibility of conveying the disease to his progeny or other mem- 
bers of his family; as to the disfigurement of his person that may 
result; as to the scars which he may carry for the remainder of his 
life; as to the possible recurrences of his malady in the future. The 
responses to these questions will largely depend on the prognosis of 
the physician. 

Some diseases of the skin are acute, pursue a rapid course, and 
are prompt to disappear. Others are chronic, rebellious to treatment 
of the most energetic and skilful character. Others, again, though 
not shortening life, are never relieved while life is continued. Some 
disappear only to reappear at more or less regular intervals. There 
are cutaneous diseases which affect one individual but once in his 
lifetime; others which reappear at the instant the patient is again ex- 
posed to their exciting cause. There are cutaneous diseases so dis- 
torting and destructive in their effects that their victims have com- 
mitted suicide under the influence of the morbid emotions which have 
been as a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its exciting cause, and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne; and the man or 
woman affected with syphilis has been made wretched for years 1>\ a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 



94 GENERAL PROGNOSIS 

influenced by that demanded by the other; thus, there is occasional 
coexistence of syphilis and phthisis. Pruritus may be associated 
with albuminuria; and the eczema of an infant starving for want of 
breast-milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prog- 
nosis of the disease of the latter will largely depend the professional 
success of the physician. Scrupulous honesty should here he welded 
with all the skill that science can command. That a disease does not 
endanger life is not an argument in favor of its amenability to treat- 
ment. The practitioner should never suffer himself to be pushed by 
hi^ patient to the position that an obstinate disease is readily manage- 
able. It is the height of folly to estimate lightly herpes zoster of the 
forehead, for the reason that it is not infrequently followed by disfigur- 
ing scars. lie who engages to relieve an alopecia areata in the month 
may have a year in which to repent hi> precipitancy. There is no 
way in which the conscientious physician can so readily secure the 
confidence of his patient, and with it that willingness to submit to 
appropriate treatment which is begotten of such confidence, as by 
demonstrating his ability to forecast the future of a disease; in other 
words, to describe accurately its prognosis. 



VII. GENEKAL THKRAPKl TICS. 



A consideration of the subject of the methods of treating skin 
diseases in general suggests at once the intimate relation which sub- 
sists between the integument and other organs of the body. The 
etiology of one largely explains the causes of disease in all. The patho- 
logical processes in each are subordinated to the same general laws. 
The principles of treatment are very similar in all the disorders of the 
body. 

The object to be attained by treating a cutaneous disease is, first, 
its complete relief; secondly, where relief is impossible, such manage- 
ment of the morbid process as will mitigate its severity and render 
the victim of the disease more comfortable. A higher and more 
scientific achievement than either is the prophylaxis by which man 
is enabled to escape the disease altogether. He can by his wisdom 
largely diminish the danger to which his integument is exposed; he 
can, to a certain extent, shelter himself from extremes of temperature, 
traumatism, toxic agents, and contagious diseases; he can, by observ- 
ing the simple rules of hygiene, fortify his skin against the lesser evils 
which may befall it. Here, however, the subject under consideration 
involves disease which is actually present and in progress. 

The management of diseases of the skin demands of the practi- 
tioner a sound knowledge of general medicine and an experience in 
disorders other than those of the integument. Dermatology is a 
branch of general medicine, and he who would succeed in the one 
department must at least be at home in the other. He who cannot 
succeed in the one field will almost surely fail to secure the best re- 
sults in the other. Much indeed of the management of diseases of the 
skin can be correctly described as the pure practice of medicine. 
Many of the methods, most of the means of diagnosis, much of the 
pharmaceutical aid utilized by the general practitioner, are indis- 
pensable in the field of dermatology. 

It is scarcely needful to set it down at this date that the old doc- 
trines respecting both the danger of "driving in" certain diseases 
of the skin, and of the importance of "driving out" others, are relics 
<>f a superstitious ignorance. There is no disease of the skin the 
continuance of which offers a bar to other disorders or furnishes a 
guarantee of the future health of the patient. There is no disease 
<>f the skin which does not call for relief as promptly as the require- 
ments and safeguards of science will permit. The retrocession of the 
exanthematous symptoms of a systemic poison is not of the class of 
involution of lesions to which attention is here directed. 



96 GENERAL THERAPEUTICS 

In beginning the treatment of disorders of the skin it is scarcely 
necessary to repeat that the diagnosis should be established by the 
methods already detailed; and that in attempting to adjust remedies 
to the morbid state due attention must be given to the past history of 
the complaint, to its remote or immediate causes, to its duration, to 
the nature of the disease (whether the latter has changed in type or 
severity since the beginning), and in particular to the special features 
presented at the moment of instituting treatment. The matter of 
diet is one with respect to which experts are not as yet upon all points 
agreed. In general it may be said that in all inflammatory affections 
the diet should include food which is simple, digestible, and free 
from excess of proteins and carbohydrates. The diet appropriate 
for the gouty state in the majority of gouty patients suffering 
from dermatoses must be rigidly enforced, even admitting that too 
severe a regimen is to be deprecated for the gouty when not actually 
suffering from a crisis of the disease. In all attacks of urticaria the 
food permitted should be made to correspond carefully with the list 
of articles known to be incapable of aggravating the disorder; and too 
much importance cannot be attributed to the regulation of the food 
in infants and children affected especially with eczema. In glycosuric 
xanthoma, in the pruritus of albuminuria, in the tuberculoses of the 
skin, in acne cachecticoruin, and in other disorders the selection of a 
dietary appropriate to the systemic state is of vital importance. On 
the other hand, it is to be conceded that in some cutaneous maladies, 
such as vitiligo, in the disorder- due to vegetable and animal parasites, 
in molluscum, and in other affections which might be named, the 
subject of dietetics is without importance. 

Like all other diseases of the body, those of the skin may be divided 
into three classes with relatively fixed limits. 

The first da— embraces all the diseases which have a natural tend- 
ency to pursue their course to a favorable termination. It includes 
all those affections which, either mild or severe, require absolutely 
no treatment of an active character. It is the duty of the skilful 
physician to watch the evolution of these maladies, and to discharge 
a most important part by refraining from therapeutic measures which 
in such cases might prove hurtful. By his judicious counsel, also, 
he hinders patients and their friends from pursuing a course wmich 
might prove prejudicial to the disease. 

The second class embraces all those skin affections which are either 
inevitably fatal or hopelessly remediless while life is prolonged. For- 
tunately, this includes but a small proportion of the large list. Here 
the duty of the physician is plain. He should assuage pain, attempt 
to relieve deformity, administer to the comfort of the afflicted in 
other ways, and by his patient courage inspire confidence and hope. 
It must not be forgotten that the skill of man has not yet reached 
the acme of human need. In the presence of many diseases of the 
body he stands absolutely helpless, and the speediest way to success 
in such cases is to begin by an honest admission of the plain fact. 



ARSENIC 97 

The third class of affections naturally embraces all not included 
in the first two named. Here disease may be prolonged or be short- 
ened in its course, rendered acute or chronic, made more or less en- 
durable, permitted to become inveterate, or absolutely be relieved 
by prompt and energetic measures, according as it is or is not judi- 
ciously and skilfully managed. Here are gained the most brilliant 
successes of the dermatologist; here also occur his most humiliating 
failures. 

In the presence of a cutaneous disease which requires treatment 
the question naturally arises as to whether this treatment shall be 
internal that is, by medicaments ingested; or external — that is, by 
local therapeusis; or by combination of the two methods at the same 
time. 

Internal Treatment. — With regard to the question of internal treat- 
ment, which is one of pressing importance, it can safely be said that 
there is no remedy to be given by the mouth that can be described 
as certainly and specifically curative of the diseases of the skin. 
The number of medicinal agents employed with this end in view is 
incredibly large, by far the greater part being obtained from the vege- 
table kingdom. With few exceptions, some of which are enumerated 
below, the most esteemed of these agents exert only an indirect thera- 
peutic effect upon the integument. The larger number- of medica- 
ments thus used are, it must be admitted, without value of any kind, 
but will probably continue to be vaunted as possessing specific virtue 
so long as credulity, on the one hand, and avarice on the other, move 
the mass of mankind. 

Arsenic has long stood at the head of the list of remedies as valu- 
able, when ingested, for the relief of cutaneous disorders. It is known 
to exert its effects almost exclusively upon the epithelia of the skin, 
and upon these, so far as therapeutic effects are concerned, only when 
they are the seat of subacute and chronic exudation. Upon the acutely 
inflamed epidermis the action of arsenic is unfavorable. If given 
for long periods of time, it may produce a generalized pigmentation 
and, occasionally, a generalized hyperkeratosis of the skin. It fre- 
quently produces excessive keratosis of the palms and soles, which 
in special cases has terminated in cancer of the skin. Operating 
favorably in this limited class of cases, it also operates slowly, requir- 
ing months for the production of its curative effects. Its adminis- 
tration is attended at all times with the hazard of producing toxic 
effects, which, however, when the result of the exhibition of the drug 
in medicinal doses, are limited usually to a mild exanthem upon the 
skin, moderate corvza, and some redness from congestion of the vessels 
in the eyes and eyelids. 

Arsenic is used chiefly in psoriasis, acne, squamous eczema, pem- 
phigus, and lichen ruber, its doses in case of children being relatively 
large. It should be administered only after eating, and a minimum 
(\i>m> first be employed in order to test the susceptibility of the patient 
to its action. It should be remembered that the toxic effect of this, 



98 GENERAL THERAPEUTICS 

as also of several of the other drugs mentioned below, is often speedily 
noticed after the first exhibition of a relatively small dose. Toleration 
once established, the dosage may be cautiously increased. 

The forms in which arsenic is usually administered are: arsenic 
trioxid usually dispensed in the form of tablet-triturates made up 
in different and most commonly administered doses; the liquor potash 
arsenitis (Fowler's solution); the liquor arseni et hydrargyri iodidi 
(Donovan's solution); the liquor arseni chloridi (de Valangin's solu- 
tion); and the Asiatic pill. Duhring's modification of this pill is 
obtained by making 2 grains (0.13) of arsenic trioxid and .'}2 grains 
(2.13) each of black pepper and licorice powder into thirty-two pills 
by the aid of a sufficient quantity of gum Arabic and water. Arsenic 
is also at times advantageously combined with other indicate! 
medicinal substances, such as iron and potassium iodid. 

An unprejudiced view of the value of arsenic, even in eases properly 
selected for its Internal administration, justifies the conclusion that 
it is in diseases of the skin a remedy of uncertain effect, and in that 
proportion disappointing. After collation of the experience of experts, 
it has been shown that the common practice of giving arsenic in many 
cutaneous diseases is both harmful and irrational, not merely because 
of its effect in inducing cutaneous congestion and pruritus, but also 
because of the reliance placed upon it to the exclusion of other and 
better methods of treatment; and that the beneficial effects supposed 
to follow its administration are often due to other causes. No series 
of carefully recorded cases has ever been published in which notable 
therapeutical results have been shown to result solely from its admin- 
istration. Even in pemphigus, psoriasis, chronic eczema, and lichen 
ruber, in which arsenic has been thought to possess special efficacy, 
it has in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one of 
the earliest, should be one of the last remedies to be selected in the man- 
agement of cutaneous diseases by the general practitioner; secondly, 
that, when thus selected, its value will probably prove greatest if 
the eruptive lesions be seated superficially, be generalized, diffused, or 
in evident association with neurotic symptoms; thirdly, that in any 
case its failure to relieve should not be regarded as definite if only 
Fowler's solution has been administered. 

Sodium Cacodylate. — This drug is an organic compound of arsenic 
and may be used where arsenic is indicated. It is claimed for the 
drug that large doses may be used without irritating effects, whether 
exhibited hypodermically or per os. It has been found of value in 
the treatment of psoriasis, lichen planus, and dermatitis herpetiformis. 
The dosage should be smaller than commonly recommended, even 
though it has the reputation of being non-toxic. A safe quantity to 
begin with ranges from gr. ^ (0.002) to gr. y$ (0.004), given three 
times daily after food. The method most frequently employed at 
present is by intramuscular or subcutaneous injection of the drug, in 
dosage varyin from \ gr. (0.06) to grs. 4 (0.24) or more. Ampules 



lODIh 99 

containing properly measured doses, sterilized and ready for use, may 
be obtained. 
Atoxyl (Meta-arsenious-anilide). This drug lias given brillianl 

results in syphilis, psoriasis, dermatitis herpetiformis, lichen planus, 
and pemphigus. It has been exhibited in dosage much greater than 
that in which other preparations can be given. Neisser has demon- 
strated its value in syphilis in apes. While it appears to be a prep- 
aration of great merit, it is not without danger, as untoward results 
recorded demonstrate. It is given hypodermieally in doses up to 
three grains (0.2) once in three days. Great caution is recommended 
in its use. 

Mercury is a remedy of great value in cutaneous as in other affec- 
tions. Its specific action upon the liver and intestinal secretions calls 
for its employment in many cases in which intestinal elimination is 
deficient, in which there is habitual constipation, and in which there 
is a decided tendency to congestion of the blood-vessels of the head, 
of the anogenital region, and even of the lower extremities. In all 
of the distinctly gouty dermatoses, in all eczemas of the florid-faced 
type of patients, in many cases of intense pruritus resulting from 
toxic influences, and in almost all the eczemas of infancy and child- 
hood, calomel, blue pill, and the gray powder are well nigh indispen- 
sable in securing the speediest and happiest results. Indeed, there 
are few adult patients seeking relief from a simple inflammatory 
affection of the skin and having at the same time a coated tongue, 
an offensive breath, and a loaded colon, who will not be benefited 
at the outset of treatment by free catharsis under the influence of a 
mercurial. In many cases, indeed, of aggravated types of engorge- 
ment of the skin, localized or generalized, a dose of blue mass may 
be given at night, on successive nights, or for a fortnight or more, 
and followed by a saline laxative in the morning, with the best effect 
upon the exanthem present. 

Mercury in the treatment of syphilodermata is of incontestable 
value, and its injudicious employment in many cases springs from 
that precise fact. The vulgar prejudice that many disorders of the 
skin, really not syphilitic, are obscure manifestations of lues in a 
preceding generation and amenable to mercurial treatment, is a strik- 
ing illustration of the necessity of accurate diagnosis in cutaneous 
diseases. When syphilodermata are present corrosive sublimate is 
often superseded, in consequence of its irritative effects, by the com- 
pounds of the metal with iodin. The gray powder is useful chiefly 
in case of infants and children, though its occasional development of 
the corrosive chlorid has limited its employment. Calomel and the 
mercurial pill should be employed only for transient effect, as when 
administered for long periods they are much more than the other 
preparations mentioned likely to produce ptyalism. 

Iodin. This drug and its compounds arc' chiefly used in syphilitic 
disorders of the skin, hut they possess a wider range of value than 
the mercurials in the treatment of other cutaneous affections. Here, 



100 GENERAL THERAPEUTICS 

too, the abuse of the drug furnishes a long list of cutaneous disorders 
either originated or aggravated by its employment. As in the use 
of arsenic, toleration should be established before large doses are 
exhibited. The compounds chiefly used are the iodids of potassium, 
sodium, lithium, and ammonium; iodo-nucleoid, iodipin, and iodoform. 
Iodin has been administered for the relief of the scrofnlodermata, 
lupus, keloid, psoriasis, and syphilitic affections. 

Cod-liver Oil. — This oil is a remedy of special value in diseases 
of the skin, and was for that reason held in high favor by the dis- 
tinguished Ilcbra, though its action is almost exclusively that of a 
nutrient of the general system. It is employed chiefly for its roborant 
effects, which arc similar to those of the digestible aliments. Its 
special value in the treatment of infants and children affected with 
cutaneous diseases cannot be questioned. It is, moreover, of great 
use in maturer years, and is advantageously exhibited in eczema, 
lupus and other tuberculous affections, syphilis, scleroderma, and in 
all disorders of the Integument accompanied by wasting. 

Cathartics, Alkalies, and Diuretics. These have an important place 
in the list of remedies valuable in the management of skin affections. 
Cathartics arc chiefly valuable in eliminating effete or toxic products, 
but they are effective also in reducing congestion of the body-surface. 
The value of mercurials in this connection has been already suggested. 
The saline laxatives and cathartics also are of great service, espe- 
cially magnesium and sodium sulphates, and the Iiochelle, ( 'arlsprudel, 
and Ilunyadi Janos salts. The useful and frequently ordered mistura 
ferri aeida is compounded as follows: 

1$ — Magnes. sulphat., 

Acid, sulph. arom. (vol dilut.), 

Ferri sulphat ., 

Aq. menth. piper., ad 

Sig. — A tablespoonful in hot or cold water before breakfast daily. 

The alkalies are extremely useful in all eases of gouty disorder, 
and in erythema, acne, and certain forms of eczema. The carbon- 
ates of sodium, potassium, and lithium are chiefly employed, as well 
as the liquor potassse The prevalent misconception of the value of 
lithium carbonate and other salts of the same base has produced a re- 
action which suggests a preference for one of the other alkalies when 
such are indicated. Diuretics, with the exception of water, are less 
valuable in cutaneous than in other affections, but they yet are admin- 
istered often with special advantage in inflammatory disorders. 

Water. — Water when drunk in sufficient quantities and at proper 
times is of great value as a diuretic and as an aid to elimination. Soft 
water is to be preferred, and should be drunk freely at all times except 
during meals and for an hour after eating. The best results are 
obtained by drinking a given amount (four to eight, or more, ounces) 
every hour. As such a course is usually impracticable outside of 
hospitals and health-resorts, under ordinary circumstances two or 
three glassful s may be ordered to be taken on rising in the morning 



Bias; 


45 




5j; 


4 




gr. vnj; 




50 


5iv; 


120 


M. (filtra) 



./ I BOR iNDl \ \ D PJLOi A /,'/'/ A |o| 

and before meals. The tree use of water, especially it' iced, with 
meals i> ;t fruitful source of indigestion as ;i consequence of t he chilling 
and large dilution of the stomach-contents. The vicious habits of 
rapid eating and imperfect mastication of food may often he cor- 
rected by simply abstaining from the drinking of liquids during the 
taking of food. 

Quinin, administered both as a tome and an antiperiodic, is 
largely employed in cutaneous medicine for its generally recognized 
systemic effects. It produces, in susceptible individuals, a peculiar 
smoothness and softness of the skin, which usually disappear when 
the drug is suspended. Like arsenic and iodin, it is occasionally 
the cause of a generalized exanthem, and is capable of producing other 
toxic effects, such as failure of the heart's action, dizziness, and tinnitus 
aurium, symptoms recognized under the designation of dnchonism. 
It will, of course, exhibit its happiest effects in malarial affections 
with coincidence of cutaneous symptoms, and in diseases of the -kin 
associated with a neurosis. The value of the administration of the 
quinin muriate, in very large doses to the point of tolerance, in some 
forms of general exfoliative dermatitis is described in the chapter 
devoted to that subject. 

Salol. — This is a remedy of special value in many cutaneous dis- 
orders associated with intestinal fermentation. It is particularly useful 
in the forms of pustular acne when the subject of the affection has 
an habitually coated tongue, a foul breath, and defective digestion. 
It i> also of value in certain angioneurotic disorders induced by intes- 
tinal putrefaction, indicated by indicanuria. 

Ergot and Ergotin, whether by exerting an effect upon the muscle- 
bundles or the vessels of the derma, or upon the uterus, or yet by 
influencing the general economy, are thought to possess some value 
in the treatment of several cutaneous diseases occurring in both 
sexes. Such are acne, purpura, and a few other disorders. 

Calx Sulphurata. — This sulphur compound was once regarded as 
the most efficient of its group for internal use in cutaneous diseases. 
It- supposed value in furunculosis has led to its employment also in 
eczema, acne, and impetigo. It is given in doses of from ^\> (0.006) 
t<> I (0.016) of a grain, three or four times daily. It is, however, a 
remedy uncertain in operation and of dubious effect. 

Chrysarobin. — This drug has been administered internally by 
Stocquart 1 and others, in doses of f (0.01) of a grain, for a number 
of cutaneous disorders. 

Ichthyol, mentioned later as of some value when externally em- 
ployed, has also been given by the mouth. It is administered in the 
dosage of -\ grains 0.2), three times daily, after meals. It is of 
value in acute lupus erythematosus and rosacea. 

Jaborandi and Pilocarpin, probably as a result of the free dia- 
phoresis which they excite, unquestionably exert immediate thera- 

1 Annales, 188 1, a ii. v p. l">. 



102 GENERAL THERAPEUTICS 

peutic effects in a number of cutaneous disorders, especially the 
angioneurotic group. 

Sulphur, highly esteemed as a popular remedy in cutaneous affec- 
tions, exerts but little influence upon the latter when it is ingested. 
Its cathartic effect is the chief reason for its administration. It is 
recommended by (rocker in some of the disorders of the sweat- 
function. 

Antimony in small doses is of unquestioned value in many dis- 
eases of the skin. It is, when not contraindicatcd, employed with 
advantage in psoriasis, pruritus, and some of the obstinate forms of 
eczema. 

Tar, Phenol, Creosote, Guaiacol, Resorcin, Turpentine, Copaiba, and 
Phosphorus.- These remedies have been employed internally with 
appreciable effect in certain cutaneous maladies. They have been 
used with advantage in cases of lupus, eczema, psoriasis, and pru- 
ritus; but the disagreeable effect of their internal administration 
has been to a great degree a bar to their genera] employment. The 
"perles" of phosphorus and the elixirs of the same drug obviate this 
difficulty in the instance of at least one of these articles. Creosote 
carbonate given in capsules is usually well tolerated. 

Animal Extracts, Thyroid Extract. These, and other preparations 
of the thyroid, adrenal, and other glands of the larger mammals, have 
in recent years been employed largely in various diseases of the skin. 
In myxedema decided and brilliant results have been obtained with 
thyroid extract, and it possesses some value in ichthyosis, psoriasis, 
and a few tuberculous affections of the skin. The irritating action of 
thyroid extract on the heart makes it an unsafe remedy to use except 
with caution. 

Iron.— This metal and its several compounds are invaluable in the 
management of a long list of cutaneous disorders. Iron is indicated 
in many cases of cachexia and struma; in tuberculosis of the skin; 
in syphilis; in all the anemias; and in many cases of purpura and 
pemphigus. Fortunately, iron is often well assimilated w T hen com- 
pounded with other drugs, and hence has been suggested the long 
list of compounds of iron and mercury and of iron and iodin in 
syphilis; of iron and quinin and of iron and the vegetable bitters 
in anorexia and anemia; and of iron with cathartics in atonic con- 
stipation. 

Analgesics have occupied a small space in cutaneous medicine, 
and that space should be more and more restricted. The use of 
acetanilid, of opium and its alkaloids, of phenacetin, of potassium 
bromid, of trional, of sulphonal, and of articles of the same class, 
has been indicated for relief of the tormenting pruritus, pain, and 
insomnia accompanying a long list of dermatoses. Unfortunately, 
most of the preparations devised to insure relief, after a temporary 
calmative effect, have a decidedly aggravating influence upon the 
exanthem present. To a degree scarcely noticeable in other cases 
have drug-h,)bits been formed in consequence of the temporary 



OPSONINS 103 

assuagement of the local distress when under the influence of an 
analgesic. As a rule, the mosl competent physician is he who secures 

relief for his patient without narcotizing the iktvis which arc litter- 
ing their protest by abnormal sensation. The <'\pert reserves for 
the last extremity medicines of the anodyne class in attempting to 

-(•cure relief. 

Hypodermic and Intracutaneous Injections of alcohol, arsenic, mer- 
cury, cocain, phenol, the alkaloids of opium, antitoxins, exalgine, 
of erysipelas-toxins, and other substances have been largely em- 
ployed in the management of cutaneous disorders, some with 
marked success, others with doubtful results. The most brilliant of 
the achievements in this direction is without question the relief of 
the syphilodermata by deep intramuscular injections of mercury. 
The injection of the antitoxins, 1 which have been such a boon in an 
important group of general disorders, has, on the whole, proved dis- 
appointing in cutaneous medicine. Attention has been directed to 
the special objections, in most of the affections of the skin, to the use 
of anodynes and opiated medicaments by whatever route introduced 
into the system. The temporary alleviation, when secured, is gained 
at too great a cost. 

Thiosinamin, Taurin, and other substances have been injected sub- 
cutaneously in the management of lupus, acne, eczema, psoriasis, 
lepra, and other affections. They have not as yet such an acceptance 
at the hands of the profession as would justify their employment in 
any save specially selected cases. 

Opsonins.' 2 — During the past few years opsonotherapy has attracted 
wide attention. In dermatology it is applied chiefly to infections 
induced by the staphylococcus and tubercle-bacillus. The chief 
disorders so treated are furunculosis, acne vulgaris, sycosis, lupus 
vulgaris, and scrofuloderma. Of those named above, lupus vulgaris 
seems most rebellious to the treatment. 

The method was largely perfected by Wright and Douglas, of Lon- 
don. To be properly carried out much time and good laboratory 
facilities are necessary. The method essentially consists in injecting 
hypodermatically definite quantities of sterilized cultures of bacteria 
isolated from the affected patient. 

It is proven that the serum of the blood contains substances which 
render bacteria susceptible to phagocytosis by the polyinorphonu- 

1 Sec opsonins. 

- Literati em , 

Hektoen, I>. Phagocytosis and Opsonins, .lour. Amer. Med. Assoc, 1906; \l\i. p. 
l H'7 (an excellenl exposition of the subject with full references i<> earlier work). 

Whitfield, A. The Opsonic Method in Skin Diseases. Translations of the Sixth 
International Derm. Congress, L908, pp. 273 l*s::. 

Von Eberts, E. M. Bacterial Inoculation in the Treatment of Suppurative ami 
Tuberculous Diseases ..I" the skin, alter the method of Wright, L908. [bid., pp. 284 --".mi. 

Schamberg, Jay 1'., Gildersleeve, V. and Shoemaker, 11. Bacterial Injections in 
the Treatment of Diseases of the Skin, 1908. Ibid., pp. 291 308 (with references an. I 
followed bj discussion). 



104 GENERAL THERAPEUTICS 

clear leukocytes. These substances Wright termed opsonins. The 
term is derived from a Greek word meaning "to prepare food," "to 
cook." As phagocytosis is the important feature in overcoming 
these infections, the quantity of opsonins becomes important. 

For comparison in the work, the quantity of opsonins in a normal 
individual is denoted by 1. As a rule, in an infected patient they are 
reduced to 0.3, 0.4, 0.0, or 0.8; in other words, are less than normal 
(exceptions to this occur). 

The opsonic index refers to the ratio between the amount of opsonins 
in the serum of an individual suffering with a bacterial infection and 
the amount in the serum of a normal, healthy person. 

Wright says: "Vaccines are any substances that on being inoculated 
into the body will cause the generation of a protective substance." 
His vaccine- consist of bacterial bodies. 

Two difficult problems are presented: first, the determination of 
the proper dosage; and second, the time-interval between the in- 
jections. 

Immediately following inoculation the amount of opsonins is di- 
minished (negative phase). This period varies according to the size 
of the dose and other circumstances, and is followed by an increase and 
by a rise in the index (positive phase). By employment of sensitized 
organisms, the negative phase may be eliminated. After a varying 
time, the index begins to fall again but does not descend to its former 
low level. Therefore, by properly regulating the size of the dose and 
repeating it at the right interval, the amount of protective substances 
may be kept abundant, as indicated by a high index, and clinically by 
improvement in the symptoms. 

The Preparation and Standardization of Bacterial Suspensions for 
Therapeutic Injection. — The size of the dose in the therapeutic injec- 
tion should always be controlled by an approximate knowledge of 
the actual number of bacteria. 

The method of standardizing the suspensions as originally devised 
by Wright is to be recommended. 

It consists (1) of thoroughly mixing equal parts of an even, rather 
dense, bacterial suspension in NaCl solution and a known blood; (2) 
of making and staining a thin smear; and (3) of determining the rela- 
tive number of red blood-corpuscles and bacteria in five or more fields 
under the jj objective. From this the number of bacteria per c.c. 
can readily be determined. 

Example: — Suppose that in a given case the red blood-cells are 
five times as numerous as the bacteria. It is previously determined 
that the sample of blood used contains 5,000,000 erythrocytes per 
c.mm. Hence, the number of bacteria is 1,000,000 per c.mm., or 
1,000,000,000 per c.c. If 50,000,000 are to be injected, one may inject 
Y$ c.c. diluted with b. s. XaCl sol. 

Essentials in the Determination of the Staphylococcus Opsonic Index. 
— (1) An even suspension in NaCl of a 24-hour culture upon agar of 
the proper density. This is best obtained by suspending some of the 



OPSONINS 105 

growth from agar slanl and then centrifuging down the clump \ 
24-hour-old broth culture also answers this purpose. 

(2) Washed leukocytes or washed blood for phagocytes. Ten or 
more drops of blood are obtained from a prick in the ear and suspended 
in a 2 per cent, sodium citrate solution contained in and nearly filling 
an ordinary electric centrifuge tube. This is then centrifuged thor- 
oughly until both the red and white corpuscles are thrown down. The 
citrate solution is now poured or pipetted off and normal NaCl solu- 
tion added and the corpuscles suspended and then again sedimented. 
This is usually repeated once more. The salt solution is decanted 
and the top layer, containing a large percentage of the white corpuscles, 
Is pipetted off and thoroughly mixed and placed in a small test-tube. 
This is designated in general use as the "washed blood," "washed 
leukocytes," or "blood cream." 

(3) The Sera. — The "normal pool" of equal parts of three or more 
normal sera, as well as the patient's serum, is best obtained in small 
U-tubes from a prick of the finger or the ear. After five to ten minutes, 
when clotting has taken place, the clot is separated from the serum 
by placing the tubes in the centrifuge sockets and centrifuging for 
four or five minutes at high speed. 

The method of obtaining the blood and mixing the three essential 
factors by Wright's method is complicated and requires not a little 
skill in preparing the necessary glassware. The method evolved in 
llektoen's laboratory by the use of the simple tube and a small capil- 
lary pipette, which is bent at right angles, is simple as well as accurate. 
A special incubator is entirely unnecessary. 

After mixing the pool of normal sera, a small amount is drawn up 
the capillary tube for a distance of approximately two inches. This 
point is marked with a glass pencil or a bit of India ink. A small 
bubble of air is drawn in the end. When the washed blood, and 
in like manner the bacterial suspension is drawn to the point marked 
above, in this way equal parts of the three necessary factors (the 
serum, the washed blood, and the bacterial suspension) are obtained 
and then thoroughly mixed by drawing them back into the wider por- 
tion of the pipette five or more times. The second pipette is now 
prepared. It contains the patient's serum, the variable factor. Both 
pipettes are then placed in the thermostat at 37° and incubated for 
fifteen minutes. 

Smears are now made, after mixing thoroughly, and the average num- 
ber of bacteria contained in at least fifty leukocytes determined, This 
indicates the relative opsonic power of the normal and patient's sera. 

From this the opsonic index is determined by dividing the roult 
obtained where the patient's serum was used by the result obtained 
where normal serum was used. 

For example: If the count where normal scrum was used shows 
that an average of four staphylococci was taken lip per leukocyte 
and where the patient's serum was used >liow^ five, llif opsonic index 
<>f the former is normal or unity, that of the latter ,' or L.25. An\ of 



106 GEXERAL THERAPEUTICS 

the polychrome blood-stains may be used to stain the smears. Two 
per cent, carbol-thionin solution in methyl alcohol is satisfactory. 

The administration of vaccines today is largely regulated by the 
clinical effects produced, rather than by the complicated and tedious 
method above described. The principle of vaccine treatment is scien- 
tifically correct, but a definite technique has not as yet been clearly 
evolved. While brilliant results occasionally follow their use, they 
have, in the main, not accomplished the results which their early use 
promised in cutaneous diseases. 1 

External Vaccine Treatment. — The local application of dead bac- 
teria incorporated in ointment ba>c> was first Largely used by (iilchrist, 2 
who reported his results combined with those of several colleagues, 
including the author, at the XVII International Congress of Medicine. 
Towle 3 at the same time was doing independent work along these lines. 
The method consists in the incorporation of the dead microorganisms 
in ointment bases, such as lanolin, vasclin, and cold cream, which are 
then applied on the affected areas in various cutaneous diseases. Acne 
vulgaris, eczema, eczematoid dermatitis, tuberculosis of the skin, and 
other disorders have been treated with varying success by this method. 

Autoserum Treatment. 1 Within the last two years, the injection of 
t he patienl 'a serum intravenously, subcutaneously, and intramuscularly 
has been practised with promising results. Pemphigus, dermatitis 
herpetiformis, urticaria, psoriasis, chronic eczema, prurigo, lichen 
planus, chronic ulcers, and other cutaneous disorders have been treated 
more or less successfully by this method. 

Technique.— From 40 to 200 c.c. of blood are withdrawn from a 
vein at the elbow in the usual manner, by placing a constrictor on the 
arm above and introducing a platinum needle into the vein, and allow- 
ing the blood to How directly into a centrifuge tube. Fordyce 5 sug- 
gests the tise of a MacRae needle attached to a large centrifuge tube 
as a means to facilitate the removal of the blood, which is done by pro- 
ducing a vacuum in the tube, thus causing a free flow. After removal 
the blood is allowed to clot. The clot is broken up with a glass rod, 
then centrifuged with a high-speed centrifuge for thirty to forty min- 
utes, and the serum then injected intravenously in dosage varying from 
25 to 60 c.c. Surgical cleanliness is absolutely essential throughout 
the whole procedure. Gottheil and Satenstein employ from four to 
six injections, at intervals of from five to seven days. 

Spraying. — Spraying the skin for antiseptic purposes is of value, 
and may be often employed with marked advantage. The several 

1 Cf. Gilchrist, Trans. XVII. International Congress of Medicine, London, 1913, 
Sec. xiii. Part II, p. 405: Vaccine Therapy as Applied to Cutaneous Diseases (with 
discussion); Whitfield, ibid., Part I, p. 193: The Vaccine Treatment of Skin Diseases. 

2 Loc. cit. 

3 Jour. Cut. Dis., 1914, xxxii, p. 770. 

4 Gottheil and Satenstein, Trans. Amer. Med. Assoc, Sec. on Derm., 1914, p. 124: 
The Autoserum Treatment in Dermatology (description of technique, personal results, 
and bibliography). Hilario, Jour. Cut. Dis., 1914, xxxii, p. 780: A Contribution to the 
to the Autoserum Therapy in Certain Diseases of the Skin. 

5 Trans. Amer. Med. Assoc, Sec. on Derm., 1914, p. 135. 



EXTERN I/. TREATMENT 107 

solutions of formalin are best suited to the purpose. Frigorific sprays 
for the purpose of freezing a part of the skin -elected for operation, 
as in the ease of epithelioma, are indispensable to the operator. Those 
chiefly employed are discharged from bulbs containing ethyl chlorid. 

Natural Mineral Waters. The chief value of many of the mineral 
springs and health-resorts of the United States lies in the change of 
manner of living that they invite and necessitate. Sunshine, pure 
air, recreation after the care and toil of business, change of climate, 
of foods and drinks, and even of cooks, often decide the question of 
speedy recovery. Unfortunately, both in America and in Europe, 
many of the health-resorts are peopled by unscrupulous charlatan-, 
with a tendency to attribute all the benefits to be derived from these 
sourees to the medicinal virtues of this or that particular spring, 
aided always by treatment according- to their own peculiar methods. 
Many patients affected with disease of the skin are thus made worse 
by a temporary residence at noted health-resorts, and therefore it is 
often the case that a visit to the seashore, to the mountains, or to any 
healthful place in the country proves conducive to greater practical 
results. Nevertheless, the springs of America and Europe having 
mineral constituents in many instances supply a valuable means of 
treating cutaneous diseases. The sulphur waters of Richfield Springs, 
of Sharon Springs, and of Avon Springs, in this country, as of those 
of Europe, operate chiefly by an influence exerted upon the digestive 
tract. The springs of West Virginia are examples of calcic waters hav- 
ing for the most part a diuretic effect. The fine water of the Poland 
Spring in Maine is chiefly valuable by reason of its remarkable purity. 
The alkaline waters of Colorado Springs, of Saratoga, and of other 
sources in America are rapidly securing a reputation equal to that of 
the famous Vichy, Carlsbad, and Ems of Europe. 

The chemical laboratories, however, are fast placing at the dis- 
posal of the consumer the salts, either natural or artificially produced, 
which represent the constituents of most of the mineral waters highly 
esteemed both here and abroad in the management of disease. In 
this way, the Apenta, Ilunyadi Janos, Ilathorn, Kissengen, Congress, 
Priederichsball, Rakoczy, and other waters may be produced at will 
by solution of the proper salts in water; and the latter in many of our 
large cities is now furnished after distillation and aeration in such 
purity that it competes with distilled water in the laboratory of the 
chemist and in the operations of the photographer. 

Of the chalybeate and arsenical waters, the former abundant in 
Michigan and New Vork, the latter best represented by that of Levico, 
in the Austrian Tyrol, it may be said that their use i- often followed 
by excellent results, especially when the drinking of the water is 
associated with the tonic regimen and healthful environment of the 
springs from which these waters are obtained. 

External Treatment. -In the external treatment of diseases of the 
skin the indications are to hasten repair when this is possible; to 
alleviate distress, if palliatives only are admissible; to destroy abso- 



108 GENERAL THERAPEUTICS 

lutely or excise the diseased tissue when this is justifiable. The 
following are the principal substances employed as external appli- 
cations: 

Water, either pure or medicated by holding substances in solution 
or mechanical suspension, is applied either in baths or as lotions. 
Baths, local or general, may be employed for days continuously or but 
for a few moments at a time. They are given with water varying in 
temperature — cold, warm, or hot. Rain-water is to be used when 
practicable. 

Cold baths of short duration are generally followed by a sharp 
reaction, the -kin becoming conge-ted alter the normal temperature of 
the surface is regained. It i> for this reason that cold sponging of 
the inflamed skin is usually grateful so long as it is continued, and 
is succeeded by an aggravation of the symptoms which it was intended 
to relieve. Continuous applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation of the 
integument; while tepid water-baths are chiefly macerative of the sur- 
face. Hot baths an- valuable in several of the exudative and hyper- 
trophic affections of the skin. The application of watery lotions to 
the broken surface of the skin is likely to be followed by endosmosis, 
unless the specific gravity of the serum of the blood and that of the 
fluid of the bath or the lotion arc nearly the same. This imbibition 
of fluids by the broken skin is accompanied by slight swelling of the 
tissues and is productive of disagreeable sensations. 

The continuous warm water-bath, in which the patient is immersed 
either for the greater part of a day or for a few hours at a time, is an 
exceedingly valuable means of treating pemphigus, the severe grades 
of burns, and ulcerative affections of the skin. 

The most perfect of all applications of water to the surface of the 
body is that most resembling the water-bath in which the tender skin 
of the fetus is immersed for consecutive months. Here the bath is 
continuous; the temperature is that of the viscera of the living animal; 
and the delicate skin of the unborn child is anointed with a fatty sub- 
stance which interferes with the macerative action of the surrounding 
fluid so long as vitality is preserved at the average standard. The 
comfort and therapeutic value of a bath prepared and administered 
in approximation to this ideal can scarcely be overestimated. Were 
it not for the difficulties with which it is attended, so far as relate to 
many portions of the surface of the body, it would be possible with this 
single therapeutic measure to rob the exudative affections of the skin 
of many of their formidable features. 

Vapor, steam, Russian, and Turkish baths are less valuable than 
is usually supposed in diseases of the skin. The macerative effect 
they produce is not always desirable. They possess some value in 
severe general pruritus, in ichthyosis, and in keratosis pilaris. 

In acute inflammations of the skin the application of pure water, 
even when of proper temperature, is often prejudicial to the integu- 



BATHS 109 

incut, and soap-and-water washings may prove quite harmful. The 
greatest caution must be exercised in giving Instruction to patients 
as to the washing of the inflamed skin. 

Water for external application, as in the hath, is medicated l>,\ 

the addition of a large number of substances, such as marine salt, 
boric acid, corrosive sublimate, sodium and potassium salts, alum, 
tannin, the mineral acids, gum Arabic, gelatin, and bran. 

The alkaline hath, made by adding sodium bicarbonate or biborate 
to water having the proper temperature in the proportion of 12 ounces 
of either salt to 30 gallons, is usually grateful to the inflamed skin. 
Sulphur-baths are best prepared by adding an ounce of Vleminckx's 
solution 1 to the above-mentioned quantity of water. 

Baths. Sulphur-baths. — The natural sulphur-baths of Richfield 
Springs and Avon Springs, in this country, are efficacious in certain 
cutaneous affections accompanied by roughness and thickening of 
the integument. 

Tar-baths. — Tar-baths are usually given by first anointing the skin 
of the patient with the tarry substance to be employed, and by im- 
mersing the body in warm water for some hours afterward. The re- 
sulting effect can usually be accomplished as well by other measures. 

Salt- and marine-baths possess the highest value with respect to 
the general health of the individual; and are advantageously em- 
ployed over the body-surface when, for example, the head alone is 
affected with a dermatosis (rosacea, acne, erythema), and when the 
salt is not brought into contact with the morbid surface. In very 
many eases a sea- or salt-bath produces aggravation of a cutaneous 
affection, and, indeed, in some eases, is capable of begetting the same. 
A properly directed salt-bath or lotion, however, is at times positively 
beneficial, not merely in chronic, but also in acute affections of the 
skin. 

The strength of the usual marine salt-bath is J pound to the gal- 
lon, though 10 pounds of the salt are often added to 25 gallons of 
water with advantage. The sea-salt is not preferable to the article 
obtained from the natural brine-wells of the interior of the country. 
For invalids the skin of the body may first be well rubbed with the 
finest table-salt, well warmed in an oven, after which a tepid or warm 
bath may be used to cleanse the surface. 

Antiseptic-baths. — These baths are most often employed by the 
surgeon. In the management of skin-affections local baths of boric 
acid in hot or cold water may be employed. The acid is soluble in 
about 25 parts of cold water. Corrosive-sublimate baths are employed 
in the strength of 1 drachm (4.) of the mercurial to 30 gallons of 



M. 



'In- formula is: 






U Calcis, 


.Vs; 


If. 


Sulphur, sublim., 


5j; 


32 


Aq. dest,, 


3x: 


320 


Coque ad gvj [200] deinde filtra. 






Sig. -"Vleminokx'a Solution." 







110 GENERAL THERAPEUTICS 

water. Local baths thus medicated are often employed in the cleans- 
ing of ulcerated and suppurating surfaces with a view to subsequent 
dressing. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, phenol, hydro- 
cyanic acid, zinc, bismuth, mercury, lead, and alkaline bicarbon- 
ates and with sodium biborate. It is rendered stimulating by the 
admixture of alcohol, most of the acids and alkalies in stronger solu- 
tion than in the soothing or sedative lotions, and also by a large num- 
ber of substances which operate upon the surface either mechanically 
or chemically. Water is also rendered astringent when tannin, lead, 
and similar medicament- arc dissolved in it; and by its union in vari- 
LOUS proportion- with soaps and alkalies a solvent effect is produced 
cither upon the cuticle itself or upon pathological or foreign products 
upon its surface. 

Soaps. Soft soap (sapo viridis, sapo mollis), made by the addi- 
tion of caustic potash in an exec-- of between i> and 4 per cent, to an 
animal fat, is a substance exceedingly useful in the treatment of skin 
diseases. It is used for the purpose of producing either a detersive or 
stimulating, and at times a slightly destructive, effect either upon the 
surface of the skin itself or upon pathological accumulations upon 
the -lirfacc (crusts, scales, etc.). It. may be used as a plaster or with 
water; and tin- last either in substance or by the aid of the widely 
known "Spiritus Saponis Alkalinus," which Ilebra first devised: 2 
ounces Mil. of -reeii soap to 1 ounce (32.) of alcohol, flavored 
with spirit of lavender. The hard or soda soaps are employed chiefly 
for toilet purposes. 

"Over-fatty" or "superfatted" soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight excess 
of unsaponih'ed fat. They are exceedingly mild in their detersive 
action upon the skin, though the lather produced in their use is not 
so abundant as that with the alkaline soaps. These are usually pro- 
prietary articles. 

Medicated soaps, containing phenol, glycerin, tar, sulphur, and 
various oils, are sold in the shops; but they usually contain so 
small a portion of the individual medicament from which each is 
named that they are practically worthless except for purposes of ablu- 
tion. Under cold pressure they may be made to contain medicinal 
substances in therapeutic proportions, but other forms of administra- 
tion of such medicaments are preferable. 

Fatty and Oily Substances are applied to the skin either directly, 
by pouring or by friction, or by the mediation of compresses, or 
bandages, which are saturated or are spread with the material to be 
applied. The oils may be used for either nutritive, soothing, or stim- 
ulating effects. To the first and second classes belong cod-liver, lard-, 
olive-, almond-, linseed-, neat's-foot, castor-, and similar oils; to the 
third class belong the oil of tar, of cade, of white birch, of the cashew- 
nut, and of juniper. 



FATTY I VD OILY SUBSTANCES I I I 

Fatty substances are also applied in the Form of ointment or 
pomades. They are compounded with various medicinal *ub tances, 
according to the requirements of each case, such as the sail of mer- 
cury, zinc, copper, lead, and sulphur; pyrogallol, chrysarobin, phe- 
nol, and hyposulphurous acid; tar, camphor, iodoform, balsam of 
Peru, chloral hydrate, and the extracts of opium, and belladonna. 

Vaselin. — The products of petroleum refinement represented by 
this ointment, though not true fats, are employed increasingly for 
similar purposes. They are particularly useful as bases for oint- 
ments for applications to the hairy portions of the body, such as the 
scalp, where more consistent salves paste the hair to the surface in an 
unsightly mass. 

In the class of soothing" ointments, which are required in many cases 
in which the skin is the seat of a severe pruritus or of burning sensa- 
tions, may be named the diachylon, benzoinated zinc-oxid, "cold- 
cream," lanolin, cucumber, petroleum, spermaceti, cacao-butter, and 
olive-oil with vaselin ointments. Those medicated with the several 
oleates and with the salts of bismuth, zinc, or lead are often of great 
value. As a rule, however, in most cases calling urgently for soothing 
applications, fat-containing dressings are not to be preferred to lotions 
or dusting-powders, or the two last named in combination. Ointments 
are rubbed gently over the affected surface, but they are more efficient 
when spread on bits of soft muslin and kept in contact with the skin. 

McCall Anderson's ointment has long been employed for soothing 
inflamed surfaces. It is compounded by adding 1 drachm (4.) of bis- 
muth oxid to 1 ounce (32.) of oleic acid, 3 drachms (12.) of white wax, 
9 drachms (3(3.) of vaselin, and a few minims of the oil of roses. Ten 
parts of lanolin, with 20 of lard and 30 of rose-water, make another 
useful combination. Many of these ointments have been found to 
be irritating on account of the fatty acids which they develop, espe- 
cially in hot weather. They may be kept sweet by the addition of a 
small quantity of formalin to each jar compounded. 

The following formulae are also useful: Boric acid, white wax, and 
paraffin each 10 parts, oil of sweet almonds 60 parts (II. Ilebra); 
Bismuth oxid 1 drachm (4.), white wax drachms (24.), vaselin 
and olive-oil, of each 1 ounce (32.); Boric acid 1 part, glycerin 24 
parts, anhydrous lanolin 5 parts, vaselin 70 parts (Duhring's "boro- 
glycerin cream ointment"). Other fatty applications are prepared 
by adding olive-, sweet-almond, or cottonseed-oil, as well as lard 
and lanolin, to lime-water in nearly equal proportions. These furnish 
a thick, emulsified substance, which requires to be well shaken before 
application. Any one of these emulsions may be medicated at will 
l>\ the addition of zinc, bismuth, calamine, or other insoluble sub- 
stance, which is mechanically mixed with the fatty emulsion when 
the whole is well shaken. 

Stimulating ointments are usually made by the addition of such 
substances as tar, mercury, resorcin, salicylic acid, pyrogallic acid, 
chrysarobin, or sulphur to any one of the several salve-bases in com- 
mon use. 



112 GENERAL THERAPEUTICS 

Glycerin, even the best, when applied in its purity to the skin is 
usually irritating. It is, however, exceedingly useful when diluted or 
made a component part of lotions and ointments. When combined 
with starch in different proportions it makes a series of combinations 
known as glycerols or glycerolats. These combinations are pasty, 
semisolid substances, which are capable of varied medication, as in the 
glycerol of lead snbacetate. They are useful chiefly as protective^ 
of the skin-surface. Glycerin, u^v(\ in a fluid soap, is an exceedingly 
valuable agent when a milder effect is desired than that produced by 
the spirit of soap described above. The Vienna preparation known as 
Sarg's fluid soap is an admirable substitute of this sort when a soft 
shampoo is required for the sealp. 

Pastes employed for local application in diseases of the skin have 
been perfected greatly by Lassar and I'nna. 1 

These pastes are valuable, especially in the exudative affections, in 
which salves are often either not well tolerated or actually prove irri- 
tating to the skin. The pastes, when applied to such surfaces, form a 
protective and adhesive dressing, which may be medicated as desired. 
One of the best and most serviceable pastes is: 

ty — Zinc. Btearat. cum. acetanilid., 

()!. oliv., I 

Unguent, aq. ros., £8 oij; 8| M. 

Or the following modification of Lassar's paste: 

ty — Zinci oxidi, 

Talc, aa 3ij; 8 

Acid, salicylic, gr. x; 66 

Vaselin, 3ss; 16 M. 

Equal parts of lanolin, vaselin, talc, and zinc oxid form a base 
that is stiffer than the preceding and adheres better. To these bases 
may be added various remedies in desired proportions. 

Dnhring's modification of the original Lassar paste is: boric acid, 
9j (1.33); starch and zinc oxid, each 3ij (8-); vaselin, §j (32.). 
Unna employs: starch, 3 parts; glycerin, 2 parts; water, 15 parts; 
boiled down to 15 parts. Half the quantity of any desired medica- 
ment may be added to the amount ordered. Paraffin may be added 
in the making of very stiff pastes in the proportion of equal parts of 
this substance and water, twice the quantity of lanolin, and about 
yV of white wax. 

Other pastes are prepared with kaolin (terra alba, or Armenian 
bole, of red color when it is desirable to have the application resemble 
the color of the skin), gum, lead, dextrin, glycerin, and other sub- 
stances. Formulae for each are appended. 

Kaolin in a pure state, with equal parts of vaselin or glycerin, or 
with almond-, olive-, or linseed-oil in the proportion of two to one, is 
readily applied in a thin layer over the skin. 

1 Monatshefte, 1884, iii, p. 38. 






PASTES 



I 13 



For making lead-pastes, litharge is boiled with twice the quantit; 
of vinegar until the hitter has evaporated and then- is left a damp 
but drying paste, which on occasion may be remoistened with a 
small quantity of vinegar. 

1$ Lithargyr. subt. pulv., Sjssj '•"' 

Aceti, 5ijssj 75 

Coque usque ad consistent, pastae: deinde adde ol. lini [v. glycerini, v. o\. 
olivffi], 10.— M. 

In the two forms of paste above described the adhesive and desic- 
cative qualities are obtained from the main ingredients, but in those 
resulting from combinations of gum, starch, and dextrin these results 
are for the most part obtained by the addition of other ingredients, 
such as sulphur or zinc. A good basis, semisolid, rapidly drying, and 
fixing its ingredients well upon the surface, is the following: 



1$ — Zinc, oxid., 


5jss; 


45 


Acid, salicylic, 


5ss; 


2 


Amyli oryzse, 






Glycerin., 


aa oiij; 


12 


Aq. dest., 


Sijss; 


75 


Coque ad.,5ivss (145). 







For a sulphur-paste 



1$ — Sulphur, prsocipit., 


5jss; 


45 


( 5alc. carb., 


5ss; 


2 


Zinc, oxid., 


5ss; 


15 


Amyli oryzae, 


oiij; 


12 


Glycerin., 


gss; 


15 


A q. dest., 


5ijss; 


75 


Coque ad., 3iv (120). 







To make use of dextrin, the official pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half- 
weight of glycerin is required if powders are also combined with the 
paste —e. g.: 



l\ — Zinc, oxid., 




5jss; 


Dextrin., 






Aq. desl ., 


aa 


5ss; 


Glycerin., 




5jss; 


Sulphur, sublim. [vel. sod. 






sulpho-ichl hyol.], 




.") ss ; 


( loque. 







A mixture of dextrin and lead is thus prepared: 



3— Lithargyr., 

Acet ., 






Si; 

5jss 


( loque ad remanent 

Adde: 

1 Vxtrin., 

Aq. desl ., 
( Uycerin., 


, 50. 


aa 


5ss; 


( loque. 








8 









.III 



15 



114 



V.ESERAL TUKh'M'KrTICS 



If too consistent, these pastes are made to spread easily by the 
addition of a few drops of hot water. 

For gum-pastes, gum Arabic is used in the proportion of 1 part 
of the mucilage and glycerin to 2 parts of the powder selected, mixed 
without heat — c. g.: 



M. 



1$ — Zinc, oxid., 

Hydrarg. oxid. rub., 
Mucilag. acae., 
( rlycerin., 


aa 


5jss; 

oss; 

S - : 


45 
2 

15 


i; ( 'id . prseparal ., 
Sulphur. Bublim., 
Picis liquid., 

Amvli. 


aS 


5ss; 
5 i j ; 
5ss; 


'2 

8 

15 


Mucilag. acac., 
( rlycerin., 


aS 


5sb; 


15 


i; \cid. Balicylic, 
( rlycerin., 
Mucilag. acac., 
( )1. ricinij 




5 88 J 

5ss; 


15 
15 

10 



M. 



M. 



The following details are to be noted respecting the availability of 
these pastes for different ingredients' Lead is best used as an acetate, 
either in a simple paste or with dextrin, the carbonate, oleate, and 
iodid combining well with both. Zinc oxid and sulphur combine 
well with kaolin, lead, Starch, dextrin, and gum. Sulphur combines 
well with the three last named, poorly with kaolin, and not at all with 
lead. Ichthyol suits well with all save the gum-pastes. Naphthol, 
calomel, corrosive sublimate, red and white precipitates, phenol, chlo- 
ral hydrate, camphor, and salicylic acid can be incorporated with 
all, the last named in smaller proportion with gum-pastes. Tar is 
better united with starch, dextrin, and gum than with the others. 
Iodin and iodoform naturally do not suit well with the starch- and 
dextrin-pastes. Chrysarobin and pyrogallol are united with kaolin 
and gum-pastes, and should not be added to them. Fatty and soapy 
substances, if commingled in large amounts with these pastes, injure 
their special properties. 

Glycogelatins are useful for protecting a surface and excluding 
the air. They are made with varying proportions of glycerin, gelatin, 
zinc oxid, and water. When cold they are solid, but when melted on 
a water-bath can be painted readily over a surface, upon which on 
cooling they fo r m an adherent protective coating. Before the gelatin 
has hardened on the skin it is well to pat it with cotton, or to lay over 
it a piece of thin gauze or muslin to form an additional protection and 
to prevent the paste sticking to the clothing. A firm but soft and 
flexible gelatin is made by mixing on a hot-water bath 1 part of zinc 
oxid, 2 of gelatin, 3 of glycerin, and 4 of water. More gelatin in the 
preparation makes it firmer and causes it to dry more quickly. A 
greater proportion of glycerin, on the other hand, interferes with the 



POWDERS I 15 

complete drying of the surface, bill makes a softer preparation, more 
acceptable to some skins, and very useful where a bandage can be 
applied. Zinc oxid helps give body to the gelatin, f>ut it' used in too 
large proportion interferes with the coherence of the preparation, so 
thai it cracks when dry. T<> the glycogelatins may be added white 
precipitate, sulphur, ichthyol, thiol, chrysarobin, iodoform, or other 
antiseptics. Some drugs, as salicylic acid, resorcin, naphthol, and 
phenol tend to destroy the coherence of the gelatin. Fox says thai 
this obstacle may be removed by adding to the paste 5 to 10 per 
cent, of fresh lard. 

Varnishes containing glycerin and a single gum are often very 
serviceable in protecting the skin. They are especially useful on the 
face, as they are transparent and inconspicuous. 

Pick's varnish (linimentum exsiccans) is made as follows: 

1$ — Tragacanth, 5 parts 

Glycerin, 2 parts 

Distilled water, 93 parts 

The tragacanth is soaked in a portion of water from ten to twelve 

hours and triturated to a perfectly smooth mass before adding the 
glycerin and other ingredients ordered. The jelly may be prepared 
without delay by triturating the tragacanth with boiling water, but 
the result is not so good. 

This jelly is applied without heating and quickly dries on the skin. 
An improvement on this varnish is Elliot's bassorin paste, which 
keeps better than the former. The formula is as follows: 

1$ — Bassorin, 
Dextrin., 
Glycerin., 
Water to make 

This should be kept in a tightly closed jar, as it dries rapidly on 
exposure to the air. Like the other pastes, it not only serves as 
a protective coating, but also as a base for the application of other 
remedies. 

Powders are mechanically dusted over the surface of the skin for 
the purpose of protecting it, and occasionally, also, to produce an 
astringent or antipruritic effect. To be serviceable, they should 
generally be rendered impalpable by sifting them carefully through a 
fine silk bolting-cloth. They are composed of starch, talc, magnesia, 
jycopodium, calamine, bismuth, boric acid, the several stearates, cam- 
phor, tannin, zinc oxid, iodoform, rice, kaolin, magnesium silicate, 
orris root, salicylic acid, aristol, europhen, and similar substances. 
The articles sold by grocers as "gloss starch" and "corn-starch 
farina" are usually much more finely bolted than the dusting-powders 
extemporaneously prepared by pharmacists. All starchy substances 
are open to the objection of forming little pasty rolls or "cakes" when 
wetted with serum or with sweat. Lycopodium, which consist> of 
irregularly shaped globular pollen-sporules, never behaves in this 



5jss; 


45 


3vj; 


24 


3ijss; 


10 


oiij; 


90 



116 GENERAL THERAPEUTICS 

way, and is, for that reason, deservedly popular. Zinc-stearate with 

acetanilid is excellent for similar reasons, and when dusted on the 
surface forms a dressing impervious to moisture. 

Medicated powders may Ik* first dissolved in alcohol, ether, or chloro- 
form. The solution is then mixed with starch or with French chalk. 
Evaporation of the menstruum is conducted without artificial heat, 
and a line starch or chalk-powder results. 

For absorbent purposes Grundler 1 has shown that by far the most 
effective powder is magnesium carbonate. 

Plasters arc employed when it is desired to exert a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin-plasters are less useful in skin diseases, be- 
cause more irritating, than the Lead-plasters. In the zinc-oxid adhe- 
sive plaster the irritating effects of the resin have been entirely over- 
come, and the result is a plaster which has excellent adhesive qualities 
and which rarely causes irritation even to sensitive skins. It thus 
answers admirably where simple protection is desired, and may be 
safely employed in order to retain other dressings in place. Tuna's 
plaster-mulls arc described below. The mercurial plasters are useful, 
especially in syphilitic lesions of the skin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by I'nna. His salve-muslins, 
or salve-mulls, are strips or bandages of muslin thoroughly impreg- 
nated and thickly spread with ointments medicated with almost every 
desirable substance, from zinc-oxid to tar, thymol, salicylic acid, and 
mercury. They are elegantly made, and when exported are sur- 
rounded by impermeable tissue, so that they remain fresh and sweet 
for several weeks, or even for months if kept in a cool place, but de- 
teriorate rapidly if exposed to the air of a warm room. They are 
efficacious, and, as a rule, well liked by patients. They are available 
in skin diseases of the exudative class affecting the extremities, but 
should be avoided when not recently prepared. 

Luna's plaster-mulls seem to be less useful. They are plasters 
thinly spread on gutta-percha cloth, and manufactured with a wide 
range of medicinal constituents. They serve a good purpose in the 
protection of parts of the skin exposed to friction. 

Salve-pencils (stilt unguentes) and Paste-pencils (stili dilubiles), 
the latter destitute of fat and soluble when moist, the former insol- 
uble in water and compounded of fatty substances, are pencil-sized 
crayons made with wax, gum, and starch, for application to limited 
areas of the skin. The several mercurials, arsenic trioxid, cocain, 
salicylic acid, and other medicaments may be applied in this way to 
the surface. 

Poultices. — These are not often ordered in the management of dis- 
eases of the skin, except for the purpose of softening crusts with a 
view to their removal. They are made, both warm and cold, with 

1 Monatshefte, 1888, vii, p. 1029. 



TAR 117 

linseed-meal, potato-starch, bread and milk, oatmeal, and cornmeal. 
These applications are objectionable in all conditions in which a 
macerative effed of the epidermis is produced; and also in which 
microorganisms may find a culture-field in the mass of the poultice. 

Poultices, in any needful case, may be made antiseptic by the addition 
of formalin, boric acid, or mercuric chlorid. 

Lanolin, or wool-fat, was first introduced as a salve-base by Lie- 
breich, of Berlin. It is a substance obtained from keratinic tissues, 

and contains cholesterin-fat instead of glycerin, with but 30 per cent. 
of water. It has a bright-yellowish color, a distinct odor of the sheep, 
and is neutral; when pure it is never acid in reaction. The refined 
product is free from cholesterol compounds and requires no fatty 
addition. This substance is readily absorbed from the surface of the 
skin, and, either pure or medicated, may be regarded as a useful addi- 
tion to the bases of ointments. The adeps huicr answers the same end. 

Eucerin 1 was introduced by Unna. It is made by the action of some 
substance obtained from wool-fat upon vaselin. It resembles lanolin, 
and is capable of taking up large quantities of water. It is recom- 
mended in ichthyosis and other dry conditions of the skin. 

Oleates. — The oleates of zinc, mercury, copper, lead, and other 
metals have been employed with advantage in the topical treatment of 
disorders of the skin. Of these, the oleates of mercury and of lead are 
decidedly the most valuable. The latter is represented by Hebra's 
white diachylon ointment. The mercuric oleate is serviceable in 
syphilitic, parasitic, and other disorders. 

Vasogen. — These products bid fair to supplant the oleates in their 
ready absorption from the skin-surface. In mercurial inunction vaso- 
gen-mercury capsules supply the exact amount required for employ- 
ment at each sitting. 

Collodion and Traumaticin are employed for the purpose of apply- 
ing a remedy to the skin, and at the same time for protecting or con- 
tracting the surface to which the application is made. Traumaticin 
is the name given to a solution of gutta-percha in chloroform, in the 
proportion of 10 per cent. In this way bismuth, cantharides, sul- 
phur, chrysarobin, zinc oxid, white precipitate, iodin, and other 
substances may with advantage be applied to the surface, and the 
action of each be definitely limited to the margins of a single patch 
of disease. 

Tar. — Tar in its several varieties, crude and distilled, together 
with its derivatives, occupies an important place among efficient top- 
ical agents. In general, it seems to exert upon the epidermis a local 
influence, which extends more deeply as the remedy is continuously 
applied. At times both irritative and inflammatory effects are thus 
induced, and even systemic intoxication when absorption from the 
skin occurs. Pix liquida, or the oleum picis, is the favorite article of 
this group with most American physicians; but the oleum cadini. or 

1 Jackson, .Jour. ('ill. Dis., 1910, xxviii. |». 2!) I. 



118 GENERAL THERAPEUTICS 

oil of juniper, and the oleum rusci, or oil of birch, are rather more 
generally employed by experts. The last-named, found in purity and 
abundance and to be had at a low price, is recommended above the 
others. In Vienna the distilled oil is preferred, but there is good 
reason to believe that the crude oil is more efficacious. 

The skill of a physician intrusted with the management of a dis- 
ease of the skin might almost be measured by his success in the use of 
tar. He who has not had experience in its employment is urgently 
advised to select one member of the tar-family and learn thoroughly 
how to apply that, singly and in combination, either as a lotion 
or in salve. Properly employed, it will favor involution of lesions, 
lessening hyperemia, infiltration, scaling, and discharge. It serves 
admirably as an antipruritic. It may, however, produce severe 
inflammation of the skin. 

To produce the benign or emollient effects of tar, it is best mixed 
with sonic soothing or astringent powder, and with this end in view 
nothing is better than chalk. Spender's hints 1 for making such an 
ointment are admirable: Finely levigated chalk is strewed into melted 
lard in a stone jar, the whole being stirred until it is cold. Then at 
first the smallest quantity of tar sufficient to make a brownish smear 
of color is added to the quantity of salve employed for use. This 
color can be successively deepened at will. Auspitz advises the use 
of the tars in a pure state, applied in very small quantities with a 
strong bristle-brush and well rubbed in. In combination with one of 
the most valuable of all substances for topical use in cutaneous thera- 
peutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson 
salve modified (7. v.) represents such a combination. 

A group of substances which occupy a therapeutic position inferior 
to the tars, but which serve an important end in the management of 
cutaneous diseases by the production of similar effects, are phenol, 
creosote, salicylic acid, benzol, naphthol, iodol, thiol, chrysarobin, 
pyrogallol, resorcin, and jequirity. 

Ichthyol, 2 fish-oil, introduced to the profession by Unna, is the 
distillate of a bituminous and sulphurous deposit of petrified fishes 
and marine fossils found in the Tyrol. Its chemical formula is 
C26H36S3Xa 2 6 . It has a tarry appearance, odor, and consistency. 
It is soluble in water, partly so in ether and alcohol, and can be incor- 
porated in any desired proportion with fat, vaselin, and lanolin. It 
has been used both pure and diluted; and several proprietary articles 
(plasters, soaps, salves, and medicated cotton) are in the market. 
It has been used both in America and in Europe in cases of leprosy, 
pruritus, acne, sycosis, eczema, psoriasis, and a number of other cutane- 
ous disorders. 3 It is used in solutions of from 10 to 50 per cent, and 

1 Practitioner, June, 1883, p. 402. 

2 McMurtry, Jour. Cut. Dis., 1913, xxxi, pp. 648 to 664 and 765 to 775, incl. 

3 See Baumann and Schotten, Monatshefte, 1883, ii, p. 257; Unna, ibid., 1882, i, p. 
225; Deut. med. Zeit., 1883, iv, p. 217; Samml. klin. Vort., 1885, No. 252; Lorenz, 
Deutsch. med. Wochenschrift, 1885, xi, p. 627; Stelwagon, Jour. Cut. Dis., iv, p. 326; 
Zeisler, Chicago Med. Jour, and Exam., 1886, liii, p. 32. 



SALICYLIC ACID I I!) 

in salves of from 5 to 20 per cent, strength. A before tated, 
it is also administered internally, more particularly in the manage- 
ment of rheumatism, in doses of from L5 to 20 drops. It doc no1 
seem to have a disturbing effect upon the stomach. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four months' old infanl sank into 
a stupor two hours after its head and limbs were smeared with a salve 
composed of one part of ichthyol to five of vaselin. 

Thiol makes an excellent substitute for ichthyol for most purposes, 
and lacks the unpleasant odor of the latter. 

Resorcin, 1 in ointments of the strength of from 5 to 20 per cent., 
serves as an antipruritic and alterative. Stelwagon reports an ano- 
dyne effect following its use. The same experimenter has modified 
Mile's formula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms 
(4.-8.) of castor-oil, 5 minims (0.33) of Peruvian balsam, and 4 ounces 
(120.) of alcohol, for use in alopecia and seborrhea of the scalp. It 
is a valuable parasiticide in lotions of the strength of from 5 to 10 
per cent., and is especially useful in disorders of the seal}) due to 
seborrhea. 

Naphtol, or /3-naphtol, as it is termed chemically, first introduced 
by Kaposi, is chiefly valuable in scabies, but has also been used in 
the management of eczema, psoriasis, and other exudative affections. 
Van Ilarlingen 2 has found it to answer well in seborrhea of the scalp. 
Neisser has described renal disorders as resulting from its use in chil- 
dren, but MM. Josias and Nocard 3 report that in ordinary medicinal 
doses it is harmless. The fact that the naphtol preparations are 
odorless and do not stain the skin is to be set dowm in their favor. 

Naftalan. — This is a distillation product from crude nafta that is 
found in the Caucasus. It is a thick fluid of dark-green color and 
contains 2| to 4 per cent, of soap. It may be mixed with powders, 
thus producing an ointment of any consistency. It is advised in 
inflammations of the skin accompanied by moisture. 

Boric Acid is of great value in diseases of the skin, and is exten- 
Bively employed as a lotion and in ointments and powders. As a rule, 
it exercises a sedative effect upon the surface to which it is applied. 
I )\ er mucous surfaces it is occasionally a source of moderate irritation. 

Salicylic Acid 4 operates especially upon the keratinized tissues of 
the epidermis, softening and separating the external portions of the 
horny layer from its deeper connections. For this reason it has a 
special value in all the hyperkeratotic dermatoses. In somewhat 
weak strength it is employed as an antipruritic agent. It is most 
often employed in salves or pastes, but is also used in lotions, being 
soluble in 2.5 parts of alcohol, 2 parts of ether, or 450 parts of water. 
It is a common ingredient of most of the popular corn- and wart-cures. 

1 McMurtry. Jour. Cut. Dis., 1913, xxxi, p. 255. 

2 Amer. Jour. Med. Sci., 1883, n. s., lxxxvi, p. 479. 

3 Annates, 1885, s. ii, vi, p. 257. 

4 McMurtry, Jour. Cut. Dis., 1913, xxxi, p. Kid. 



120 GENERAL THERAPEUTICS 

Phenol, since in value as an antiseptic it has been largely sur- 
passed By other articles, is chiefly employed today upon the skin 
as an antipruritic. It is applied in the form of lotion, salve, and 
p;i>t<\ but much more often in lotions having the strength of from 
10 to 20 grains to the ounce (0.66-1.33 ad 32.). Other acids — nitric, 
sulphuric, lactic, acetic, hydrochloric, benzoinic, tannic, chromic are 
employed either for caustic, destructive, or stimulating effect, usually 
in liquid form. Tannic acid, however, is occasionally employed as a 
powder, in which form it> astringent quality is combined with the 
soothing or antiseptic effect of other substances in powder. 

Chrysarobin, Pyrogallol, and Anthrarobin are useful as cutaneous stim- 
ulants capable of determining in the skin to which they are applied a 
characteristic dermatitis limited to the site of the application. ( Chrys- 
arobin is especially useful in the local treatment of psoriasis, lepra, 
and the disorders due to vegetable parasites. It is employed in from 
1 to 10 per cent, strength, in salve, lotion, or in collodion or trau- 
maticin. A useful combination in the parasitic disorders of the scalp 
due t<> the microsporon Aiidonini or to the trichophytons is a solu- 
tion of chrysarobin in oil of turpentine, about 1 part in 250. A chief 
objection t<> ii> use is the consequent staining of the skin and articles 
of apparel. On the seal]) the hairs are turned to a yellowish-green 
shade Pyrogallol oxidizes after exposure and turns the skin a blackish 
color. It is useful iii many cases of lichen planus, eczema, and the 
diseases due to the vegetable parasites. It has been employed in the 
strength of 50 per cent, in the removal of epitheliomata. Anthra- 
robin, though inferior to both of the other articles named, is effective 
in the same general manner. 

Iodin, especially in the form of tincture, is useful as a local appli- 
cation in certain of the seborrheas, and as a parasiticide. It is often 
employed with mercury in the form of an ointment. The ointments 
compounded of the >alts of iodin with mercury, though of unques- 
tioned efficacy, are less employed today than formerly. 

Jequirity (Abrus precatorius) , employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, 
has been used by Shoemaker 1 in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar 
to a smooth paste, was added to sufficient water to make four parts. 
This emulsion was used for local application. 

Sulphur, 2 popularly employed chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous 
therapeutics as an external agent in a wide range of non-parasitic 
disorders. Hebra once regarded it as valueless in eczema, but his 
opinions on this point are not now generally accepted. It is a remedy 
of great merit in all seborrheic conditions. Precipitated sulphur is 

1 Lancet, 1884, ii, p. 185. 

2 McMurtry, Jour. Cut. Dis., 1913, xxxi, p. 322. 



MERCUR1 l_ ; l 

to be preferred to the other corn pom ids of the pharmacopoeia. It ma; 
mechanically be incorporated with salve-bases, or chemically com- 
bined with vaselin and other petroleum-products, a process by which, 
as experiments have shown, its therapeutic value is not increased. It 
is also applied, after mechanical union with various substances, as ;i 
lotion. It is irritating to the acutely inflamed skin, hut is much better 
tolerated than the tars in conditions of subacute or chronic exudation. 

Formaldehyd is a valuable antiseptic agent, most commonly em- 
ployed as formalin, a proprietary preparation representing 40 per 
cent, of the compound. Formalin in the strength of 1 per cent, com- 
monly produces a slight irritation over the thin skin of the face; and 
after application in the strength of 2 per cent., which should be rarely 
exceeded on the cutaneous surface, there follows a decided sensation 
of burning, with a resulting transient erythema. It is a remedy of 
the highest value in the treatment of syphilodermata, acne, seborrhea, 
the disorders produced by the vegetable parasites, several of the 
eczemas, impetigo, and other affections. It is well to color the solu- 
tion with a trace of fuchsin. 

Pyoktanin-blue is employed in aqueous saturated solution as a 
parasiticide in those disorders of the skin especially which affect 
regions beneath the clothing or which may be protected by dressings 
from exposure to the eye. It is highly valuable as a local and painless 
application in circumscribed patches of weeping or scaly eczema, in 
many of the ulcerating syphilodermata, in lupus, and in ringworm. 
It should be applied daily in several coats, each coat being permitted 
to dry before the next is superimposed. 

Potassium Permanganate belongs to the same category as pyok- 
tanin-blue, with the disadvantage that in some strengths it is produc- 
tive of pain, while the pyoktanin solution is unproductive of pain. 
From 2 to 10 per cent, solutions of the potassium salt may be painted 
on the affected surface one or more times daily till the desired effect 
is produced. The indications for its use are those which the pyok- 
tanin solution is intended to meet. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and non-syphilitic. The prepa- 
rations of mercury employed as topical agents in the treatment of 
diseases of the skin are of the highest value. They include corrosive 
sublimate, calomel, the red and yellow oxids, the biniodid and cin- 
nabar, the white and red precipitates, and the nitrate. The most 
commonly employed of their combinations are the "black wash," oint- 
ment of the nitrate, and mercurial ointment. Fumigation of the 
surface by vaporization of either cinnabar or calomel or the two in 
combination is chiefly employed in the local treatment of syphilo- 
dermata. The bichlorid is most often applied as a lotion; calomel 
and white precipitate in ointments; though calomel is often effec- 
tively combined with talc or starch as a powder. Startin's nitric oxid 
ot mercury ointment represents a combination of two mercurials: red 
mercuric oxid, grains (0.4); mercury bisulphate, 4 grains (0.25); 



122 GENERAL THERAPEUTICS 

simple cerate, 1 ounce (32.). Corrosive sublimate as a parasiticide 
is of great importance in the treatment of several cutaneous disorders 
due to the presence of microorganisms, as, for example, lupus vulgaris, 

Chloral-Camphor and Phenol-Camphor have value chiefly as antiprurit- 
ics. The former is obtained by rubbing together chloral hydrate and 
gum-camphor (Bulkier) until they form a clear liquid of pungent odor. 
Phenol-camphor is made by gradually adding camphor to melted 
crystals of phenol, a colorless liquid resulting, having the fragrant 
odor of camphor without that of the acid. It is a useful local anes- 
thetic agent, being insoluble in water, but freely soluble in chloroform, 
ether, and alcohol. 

Many Agents are employed upon the surface of the integument to 
produce in various degrees a caustic or destructive effect. Among 
these max be named the t hernio-eantery ( Paqnelin-knife), galvano- 
caustic apparatus, the mineral acids and alkalies, sodium ethylate, 
arsenic, zinc-chlorid, several mercurial compounds, mercuric nitrate, 
mercuric chlorid, antimonious chlorid, cupric sulphate, and argentic 
uitrate. Several of these substances in weak solution are employed 
as milder agents for the production of irritative or even inflam- 
matory effects. To the latter class should be added iodin, chlo- 
roform, tartar emetic, croton-oil, and cantharides. These destructive 
effects are of advantage in the treatment of disorders of the integu- 
ment due to parasites, either animal or vegetable. Of those employed 
fortius purpose, and not mentioned above, may be named petroleum 
and staphysagria, for the destruction of lice; sulphur, styrax, and 
balsam of Pern, for the destruction of acari; and sulphur and its com- 
pound^ and a Dumber of derivatives from tar, for the destruction of 
vegetable parasites. 

A large list of medicinal substances might be added which are 
occasionally employed in cutaneous affections, some very rarely, the 
most with questionable effect. Among them may be named alcohol, 
which is of high value as a disinfectant, and hydrogen peroxid, hav- 
ing a similar effect; ether, the opium alkaloids, cocain, belladonna, 
cannabis indica, and aconite, for anesthetic and antipruritic effect; 
and ergot, cantharides, mustard, croton-oil, tartar emetic, benzoin, 
capsicum, rosemary, and the several salts of lead. Many of the 
articles named, such as cantharides, rosemary, and capsicum, are em- 
ployed as lotions for the scalp in the several alopecias. 

The salts of zinc (sulphate, sulphocarbolate, acetate, oxid), of 
copper, alum, lead, bismuth, and other metals, are of service in dis- 
eases of the skin as productive of both astringent and stimulating or 
even of caustic effects. The careful adjustment of the dosage in each 
instance is of the highest importance, and is practically indispensable 
for the production of beneficial effects. 

Counter-Irritation over the Vasomotor Centres, as recommended by 
Crocker, is an efficient means of relieving fixed and obstinate cuta- 
neous disorders. It may be produced by the action of sinapisms, 
blisters, or caustics over the region selected for such irritation. 



MINOR iND OTHER SURGICAL OPERATIONS 123 

Hyperemic Treatment (Biers). ' This method of treatment finds 
some application In cutaneous diseases. Moth passive or venous and 
active or arterial hyperemia may be used here as well as in other 
branches of medicine and surgery. Passive hyperemia may be in- 
duced by an elastic bandage or by means of cupping. Active hyper- 
emia is induced by hot air. By one or the other of the methods, such 
diseases as eczema, psoriasis, sycosis, keloid, alopecia areata, lupus 
vulgaris, and staphylocccus infections may be benefited. 

Electrolysis is a method of the greatest value in the treatment of 
a large number of cutaneous affections, such as hypertrichosis, telan- 
giectases, molluscous tumors, and warts. It is accomplished by the 
aid of the galvanic battery in the manner described in this work in 
the pages devoted to the first of the disorders named. 

The Minor and Other Surgical Operations required in the manage- 
ment of some affections of the skin are detailed in the treatises de- 
voted to that subject. Among such procedures may be named skin- 
grafting, both by the methods of Reverdin and Thiersch, and the 
several devices of plastic surgery. Strictly dermatological procedures 
to which resort must often be made are: epilation in hyphogenous 
sycosis and other affections; massage, especially by the massering- 
ball; the operations on the face, especially in acne, when opening small 
abscesses, removing comedones, and incising papules; and multiple 
scarification, as in telangiectases and other lesions. 

Numerous surgical and other appliances are found useful as ad- 
juvants in the treatment of skin-diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in the 
retention of dressings or external medicaments. Thus, the ordinary 
roller-bandage is applicable to many portions of the body; the suspen- 
der, or suspensory bag, to the scrotum; elastic or inelastic stockings 
to the feet and legs; kid, rubber, and thread gloves to the feet and 
fingers; and various skull-caps, face-masks, and mittens are employed 
in the case of infants and children to protect affected surfaces from 
the traumatisms of scratching. 

Apart from the surgical apparatus required for ablation of tumors 
or severe operations, a number of instruments are required for the 
daily use of the dermatologist. Among these may be named: 

A set of variously sized dermal curettes. These sharp-edged spoons 
are lor erasion of the surface, and should, for general use, have in each 
a tenestrum large enough to permit the escape from the floor of the 
Bpoon of all collected substances. The small-sized spoons, however, 
with solid bowl and sharp edges, largely used in Vienna, are preferable 
for use, especially about the face, in many skin-affections. Epilating- 
rorceps, with easy springs and smooth blades meeting in perfect 
apposition. A set of Piffard's comedone-extractors, provided at each 
extremity with a differently sized, minute, spoon-shaped and perforated 
bowl, the convex surface of which is pressed over the comedo with the 

1 Biere' Hyperemic Treatment, 1908; Willy Meyer and Victor Schwieden. 



12 4 GENERAL THERAPEUTICS 

orifice immediately over the black head of the plug. This is a great 
improvement over the old-fashioned comedo-extractor shaped like a 
watch-key, and the discomfort to the patient by its use is greatly re- 
duced \ set of half-inch and four-inch lenses for examining the sur- 



FlG. 22 



mmamms ^ 



[rido-platdnum needle. 
Fig. 23 



Milium-needle 
Fio. 24 



o- 




Epilating-forceps. 
Fig. 26 










Piffard's grappling-forceps. 
Fig. 27 




Piffard's cutisector. 
Fig. 28 




Dermal curette. 

face of the skin. Needle-holders with light handles for firmly grasping 

he needles nsed in opening pustules, etc. The needles, some of them 

should be flat, with a double-cntting edge; others should be rounded 

neatly on an emery-wheel, and all of them carefully disinfected. Too 



R [DIOTHERAPY 125 

many precautions cannot be taken in the practice of dermatology with 
respecl to the disinfection of all Instruments made to penetrate the 
Bkin. Probes, exploring-needles, fine dressing-forceps, delicate I raight 
and curved scissors, and other instruments from the ordinary pocket- 
case of the surgeon are indispensable. The instruments required for 
use in connection with the galvanic battery are enumerated in the 
chapter on Hypertrichosis. 

Fig. 29 




Dermal curette. 
Fig. 30 




Hess's pleximeter, for observing the skin under pressure. 
Fig. 31 

ill 



&"U^>JVM\U8c.t" 



^> 



Piffard's modification of Unna's comedo-extractor. 
Fig. 32 



OFREAL SIZE. 



Keyes' cutaneous punch. 
Fig. 33 




Hyde's massering-ball. 

Radiotherapy 1 (Treatment by X-rays) has an established position as 
a therapeutic agent in cutaneous medicine. Among the diseases in 
the management of which it has distinct value are epithelioma, lupus 
and other forms of cutaneous tuberculosis, coccogenous and 



fans 



For complete presentation of the subject and bibliography, see: Freund, Grundriss 
ammten Radiotherapie, Berlin and Vienna, 1903; Williams, The Rontgen Raya 
in Medicine and Surgery, New Vork, 1901; Pusey-Caldwell, The Rontgen Hays in 
Therapeutics and Diagnosis, Philadelphia, L903 ; Stelwagon, Jour. Cut. Dis., L903, xxi. p. 
345 i \\ uli discussion before t he Amer. Derm. Assoc.) ; Pusey, ibid., p. .'>.V> (with discussion 
before the Amer. Derm. Assoc); Bronson, ibid., i>. .'*7f>. For recenl papers on radio- 
therapy, Bee Transactions of the Sixth International Dermatological Congress, 1908. 



126 GENERAL THERAPEUTICS 

hyphogenous sycosis, acne vulgaris, rosacea, psoriasis, hypertrichosis, 
lupus erythematosus, ringworm, and favus. The list includes diverse 
morbid conditions, but these in turn actually are remedied in many 
cases by one or the other of the therapeutic properties of the agent. 
X-rays per se are not germicidal, but indirectly, through tissue-reaction, 
they may produce such effects in a high degree, as shown by the par- 
tial or complete arrest of purulent discharge from the surface of car- 
cinomatous or other ulcers subjected to their action. They produce 
degeneration in cells of embryonic type without destroying the healthy 
stroma in which they have developed; cells also of higher differenti- 
ation an- affected early. As a consequence, hair-follicles and sebaceous 
glands may become partially or wholly atrophied under the influence 
of the pay, the result depending upon the dosage employed. 

Clinical effects of the rays upon normal skin vary from slight ery- 
thema and pigmentation to deep-seated, destructive inflammation. 
The earliest evidence manifested is cither pigmentation or erythema. 
The former may be lentiginoua or exhibited as a diffuse, brownish 
discoloration of different shades, the amount of pigment varying as a 
rule with the complexion of the patient. Usually this disappears 
within a few days or weeks, though it may persist for several months. 
Erythema appears early and soon subsides, with superficial desqua- 
mation and pigmentation, if treatment be suspended in time. The 
process usually lasts from a few days to two weeks, and is accom- 
panied by mild itching or pricking sensations. Should the inflam- 
matory process progress to a further stage, vesicles appear on the 
erythematous area. These may be either superficial and short-lived, 
soon drying and disappearing, or more deeply situated, and associated 
with greater swelling and increased redness, the whole area becoming 
denuded of its superficial epithelium and showing an excoriated and 
weeping surface (x-ray dermatitis). This surface usually becomes 
covered with a yellowish or grayish, adherent pellicle, composed of 
necrotic epithelium, which gradually retracts, its place being taken 
by normal cornified cells. In case the pellicle does not form, bluish 
islands of epithelium appear over the weeping surface, which by en- 
largement and coalescence cover the area. The new T epithelium is 
smooth, delicate, bluish-white in color, devoid of pigment and hair, 
and may remain sensitive to external influences for some time. The 
duration of this degree of dermatitis is from a few weeks to several 
months, and the subjective sensations vary; usually a burning, ting- 
ling, or itching sensation is experienced, with occasionally marked 
tenderness and some pain. In a dermatitis of serious portent, the 
subcutaneous and deeper tissue is involved. The inflammation begins 
with erythema, vesiculation, and marked swelling; the skin becomes 
cyanotic and brawny, and necrosis follows. The affected area is cov- 
ered with a dry, dark-colored, leathery, adherent mass of tissue, which 
may persist for months, is surrounded by a reddish inflammatory 
border, and is accompanied by severe pain. These lesions are chronic, 
lasting for months or years, and the cicatrix which eventually forms 



RADIOTHERAPY 127 

mi;i\ be covered with telangiectases. Fortunately, these severe burns 
are now of rare occurrence. Themajority of recorded ca es occurred 
.it'tcr long exposures for skiagraphic purposes. 

A chronic form of dermatitis occurs on the hands and sometimes 
on the (i\cv of &-ray operators, which is attended by scaling, atrophy, 
obliteration of the normal lines of the skin, telangiectases, alopecia, 
and at times loss of the nails. Ulcers and hyperkeratoses, some of 
which developed later into epithelioma, have occurred, and occasion- 
ally a condition simulating scleroderma has been noted. 1 

Of great importance in estimating probable results are the facts 
that the reaction of the skin exposed to the .r-rays occurs only after a 
period of delay, which may be prolonged for three weeks or more, and 
that the effects are cumulative. 

Pathological action of a>rays has been studied both in man and in 
animals by several observers. Schlotz 2 concludes that: First, the rays 
cause a slow degeneration of the elements of the skin, in which the 
cells, not only of the epidermis and its appendages, but also those of 
the corium, may participate. This degeneration affects the nucleus as 
well as the protoplasm of the cell. The rays also induce, but to a 
much less extent, a degeneration of the fibrous elements (collagen, 
elastin) and of the muscles. Second, when the cellular degeneration 
reaches a certain point an inflammatory reaction occurs, in which 
the blood-vessels become dilated and an extravasation of serum and 
leukocytes results. The latter then seem to act as phagocytes and to 
destroy completely the degenerated cells. MacLeod 3 adds that "the 
inflammatory reaction induced by a>rays is peculiar in that it occurs 
in a tissue the vitality of whose various elements has already been 
impaired by the action of the rays, and in that it is associated with 
greater destructive changes than those produced by actinic rays, and 
is apt to lead to ulceration and necrosis, and is liable to be followed by 
an imperfect process of repair." An agent having such properties is 
obviously of great value, but not without danger in its application. 4 

Apparatus (x-ray). — Two forms of apparatus are in common use, 
one employing an induction-coil, the other a static machine. An elec- 
tric current or storage batteries are essential when a coil is selected. 
Either apparatus will accomplish the desired end when properly 
managed. The popular idea that the static machine should be used 
for therapeutic purposes, on account of its greater safety, is erroneous, 
as serious damage has been wrought by its use. A coil having a double 
or a triple winding in the primary, which may be connected in parallel 
or in series, is efficient. It should furnish a spark-gap of the length of 
30 cm. Four varieties of interrupters are used: the turbine and the 
dip interrupters, in both of which mercury is used; the Wehnelt (or 

1 .lour. Cut. Dis., 1903, xxi, p. 52. 

1 Aicliiv, 1902, lix, pp. S7 and 241; abstr. Brit. Jour. Derm., 1902, xiv, p. 397. 
; ' Brit. Jour. Derm., 1903, xv, p. 365 (with review of Literature on pathological action 
of x-rays). 

1 rhe treatment of x-ray dermatitis is considered with other forms of dermatitis. 



128 GENERAL THERAPEUTICS 

electrolytic); and the vibratory interrupter; each of the four possesses 
some advantage peculiar to itself. A voltmeter, ammeter, and tachom- 
eter indicate, respectively, voltage, amperage, and frequency of inter- 
ruptions. Lead-plate, as a rule, is interposed between the tube and 
the skin in the vicinity of any lesion to be treated. The lead is placed 
between the tube and the patient, and should have an aperture of the 
size of or slightly larger than the lesion to be treated, through which the 
rays pass. Rontgen found that lead one-sixteenth of an inch thick 
was impervious to all rays. Practically, however, one-thirty-second 
of an inch is sufficiently thick. Aluminum screens, advised by Thomp- 
son, 1 may be interposed, when treating deeper lesions, to intercept 
some of the rays which arc absorbed superficially and which induce 
early dermatitis. The elimination of these rays allows the treatment 
t<> be pursued for a longer period without damage to the superficial 
tissues. 

Technique.- A reasonably safe technique was early devised by Schiff 
and rreund, as follows: The coil should furnish a spark-gap of :>() cm. 
A primary current of \'2 volts and \\ amperes is advised, with inter- 
ruptions of (»()() to 1000 per minute. The tube should be placed L5 cm. 
distant from the surface treated, gradually reducing the distance to 
.") cm. The time of treatment in the beginning should be five min- 
utes, this to be increased gradually to fifteen. Three preliminary ex- 
posures of five minutes each, given daily, with the tube at a distance 
of loom., arc first to be employed. If, after an interval of three weeks, 
no unusual reaction occurs, treatment is resumed and pursued. As 
there are no mean- of measuring exactly the quantity of radiation 
from a given tube, and as the reaction in each individual case must 
be the chief guide, a perfect technique cannot be outlined. By employ- 
ing a milliamperemeter, a Benoist radiochromometer, and a Holz- 
knecht radiometer, the dosage may be more accurately measured, 
these instruments being essential when the so-called single-dose method 
is followed. 2 (For details as to duration and number of exposures, 
distance of the tube, etc., consult the chapters devoted to the diseases 
in which this treatment is recommended.) Preliminary exposures with 
a view to testing the susceptibility of the patient should never be 
neglected, especially in the treatment of such disorders as acne and 
hypertrichosis. The difference in susceptibility of different patients 
to the rays is not only demonstrable, but in certain cases amounts to 
a dangerous idiosyncrasy. 

Tubes. — The greatest problem in radiotherapy is furnished by the 
tube. Successful treatment depends much on the ability of the opera- 
tor to recognize, to a degree at least, the condition of the tube em- 
ployed. Tubes are designated as "hard" or "soft." A hard tube is 
one in which, the vacuum being more perfect, there is a marked resist- 
ance to the passage of the electric current; its rays have penetrating 

1 Boston Med. and Surg. Jour., 1896, exxxv, p. 610. 

2 See MacKee and Remer, Jour. Cut. Dis., 1912, xxx, p. 528: The Single-dose X-ray 
Method. 



PHOTOTHERAPY 129 



IIIIV 



qualities and ii contains fewer of the rays absorbed superfici 
consequently the rays of such a tube affed the skin only after a Qum- 
ber of exposures. A soft tube lias the reverse effect, [ts vacuum is 
relatively low; it offers but little resistance to the passage of the electric 
current ; the rays produced in it arc largely absorbed by the superficial 
tissues; and it readily produces dermatitis. The shadow-picture on 
the fluoroscopic screen produced by a>rays from a hard tube shows but 
little contrast between the flesh and the hones of the hand; while with 
a soft tube the contrast, for obvious reasons, is conspicuous. A newer 
tube emits more .r-rays than an older tube. Tubes become hard by 
use, and if not fitted with a regulating device become inefficient. 
Rest softens a hard tube to some extent. The focus of the cathode 
rays need not be small for therapeutic work; for fluoroscopy and 
skiagraphy this is essential. A tube having a regulating device of 
some sort is preferable, as it can be softened at will. 

It follows that in the treatment of superficial cutaneous diseases 
soft, or moderately soft, tubes are preferable, even though they may 
produce dermatitis if used sufficiently. It is this quality that gives 
them their efficiency. With such tubes a large amount of treatment 
is never necessary, and the reaction should be anticipated by suspend- 
ing treatment before its appearance. By careful regulation of the 
other factors, such as the intensity of the light, etc., best results may 
be obtained. In epithelioma usually a moderately hard tube is ad- 
visable, the quality depending largely on the depth of the lesion and 
the quantity of rays usually necessary for its removal. Other ele- 
ments equal, the intensity of the rays varies directly with the strength 
of the primary current (Rontgen), and the effect varies inversely as 
the square of the distance of the tube from the surface exposed. In 
epithelioma radiotherapy possesses the advantage of being a painless 
method of treatment. As pathological cells are affected and destroyed 
with a smaller amount of .r-rays than normal cells or normal connective 
tissue, it follows that good cosmetic results may be obtained when the 
quantity of rays applied is sufficient to destroy the diseased cells with- 
out injury to other structures. 

Phototherapy. — Since 1890, when Finsen published his first report 
on the treatment of lupus vulgaris with concentrated chemical rays of 
light, the therapeutic value of light has been studied both clinically 
and experimentally in the laboratory by many observers, and the 
literature of the subject has become extensive. 1 

The bactericidal properties of light were demonstrated first by 
Downes and Blunt in 1877, and since then by many other observers. 
The fact is now well established that the chemical rays of light, if con- 

1 For bibliography, sec Mittheilungen aus Pinsen'a Lysinstitut, Nos. l I (German 
translations, Leipzig and Jena, L900 I); Leredde et Pautrier, Annales, 1902, iii s., iii. 
p. 341, and Phototherapie et Photobiologie (monograph of 267 pp.), Paris, 1903; Freund, 
Gmndrisa der Gesammten Radiotherapie (monograph of 423 pp.), Berlin ami Vienna, 
L903; M511er, Bibliotheca medica, Al.t. I) 11 (monograph of 1 Hi pp.); Hyde, Mont- 
gomery and Ormsby, .lour. Amer. Med. Assoc, 1903, xl, p. 1); and Montgomery, .lour. 
cm. Dis., 1903, x\i, ]>. 529. 
9 



130 GENERAL THERAPEUTICS 

centrated and their action sufficiently prolonged, arc capable of de- 
stroying the majority of pathogenic bacteria, though the resisting power 
of different microorganisms differs considerably. The experiments of 
Finsen, Bang, Bie, Freund, Stroebel, Busch, Jansen, and others have 
demonstrated: (1) That of all parts of the spectrum the ultra-violet 
rays are the most highly bactericidal, and are also most stimulating 
to plant and animal cells, these properties gradually diminishing in 
power toward the red end of the spectrum, where they are compara- 
tively slight. (2) The power to penetrate tissue is greatest at a cer- 
tain point in the ultra-red part of the spectrum, and diminishes in both 
directions, the ultra-violet pays being absorbed for the most part by a 
thin layer of glass or by the uppermost layer of the epidermis, and 
unable to penetrate the skin more than a millimeter. (3) The effec- 
tive rays in the treatment of skin diseases are, therefore, the visible 
blue and violet and the immediately adjacent ultra-violet rays, since 
these arc both bactericidal and stimulating to cells and have some 
power of penetration. Jansen has shown that by prolonged action 
(seventy-five minutes) of the light as employed at the Finsen Institute 
in Copenhagen, bacteria may be destroyed, in tissue exsanguinated by 
pressure, at a depth of L.5 mm., and their growth retarded at a depth 
of I mm. beneath the skin. The stimulating effects of the light prob- 
ably penetrate somewhat deeper. 

Though the earlier studies of Widmark, Hammer, and Unna on the 
production of dermatitis and pigmentation by the violet rays; of Graber, 
1 )uBois, Bert, and Lubbock on the influence of violet rays on the activi- 
ties of certain animals; the broader and more fundamental researches 
in this field of v. Sachs and Jacques Loeb; and the subsequent demon- 
strations of Friedlander, paved the way for the later investigations of 
light-therapy, to Finsen belongs the credit of having first made prac- 
tical and successful use of light in the treatment of disease. 

Phototherapy as employed by Finsen and his followers is based on 
the principle of concentrating a large number of chemical rays of light 
on a small area, at the same time excluding the heat-rays as far as pos- 
sible. A few seconds' exposure to such concentrated light may produce 
a superficial erythema, but exsanguination of the area to be treated 
and long exposures (usually one hour) are necessary to secure deep 
penetration of the light and to produce an acute inflammatory reaction 
of the tissues. Sunlight, which Finsen employed at first, and which 
still is used to some extent by his followers, in summer, is too uncertain 
in its availability for general use, and is apparently less effective than a 
strong electric arc light. 

The light from a powerful electric arc is condensed by means of a 
series of lenses so enclosed in a metal tube as to form chambers, which 
are filled with distilled water to absorb the heat-rays. The lenses are 
made of rock crystal, as glass absorbs too large a proportion of the 
ultra-violet rays. The collecting lenses are 7 cm. in diameter (larger 
sizes being difficult to obtain and very expensive), and the rays are 
brought to a focus about six or seven inches from the lower end of the 



PHOTOTHERAPY 131 

tube. Surrounding one of the divisions containing water is an outer 
jacket, through which ordinary cold water circulates, thus preventing 
overheating of the apparatus. In Finsen's original apparatus he em- 
ployed an arc light of from (>() to 80 amperes and about 70 volts. In 
each quadrant of the circle around the lamp was placed a system of 
condensers, thus permitting the treatment of four patients with one 
light. This apparatus is suitable for institutions where numbers of 
patients are to he treated daily. A smaller lamp has been devised by 
Finsen and Reyn, in which they use practically the same system of 
condensers, but by employing one lens of shorter focal distance' and by 
so directing the arc that the strongest rays fall directly on the first leu-. 
20 amperes and 55 volts give results equal in every way to those ob- 
tained by the larger apparatus. The lamp is mounted on an adjust- 
able stand, and is much cheaper to install and maintain than the origi- 
nal apparatus, and more suitable for use outside of large institutions. 

In treating a given area, the patient should be so placed that the 
light falls perpendicularly upon the surface to be treated, which is 
brought near enough to the lamp so that the rays are concentrated in 
a circle from one-half to one inch in diameter. Throughout the seance 
this position must be accurately maintained, and the area under treat- 
ment must be exsanguinated. The tissues are kept bloodless by 
means of constant pressure applied by an attendant with specially pre- 
pared compressors. These are composed of two quartz lenses so held 
together by a metal rim as to leave between them a narrow space, 
through which cold water 1 constantly circulates, <to prevent the heat- 
ing of the lenses. According to the contour and location of the area to 
be treated, the lens which comes in contact with the surface may be 
plane, slightly concave, or convex in varying degrees. For certain 
sites, as, for example, the inner canthus of the eye, compressors of 
special shape and size are made. Though in Finsen's Institute these 
compressors are usually held in place by an attendant, who thus must 
give her whole time to the treatment of one patient, they are made so 
that they can be fastened in place by means of a tape or elastic bands. 
\\ e find that by properly adjusting these bands and by carefully plac- 
ing the patient (frequently with the aid of a photographer's head-rest) 
so that the part to be treated is well supported, equally good results 
are obtained and at much less expense than when each patient requires 
the constant attention of a nurse or attendant. 

The water in the compartments between the condensing lenses 
absorbs most of the heat-rays (nearly all of the ultra-red), but trans- 
mits not only the ultra-violet rays, but also nearly all of the visible 
spectrum. Consequently, if the light be too concentrated, the heat 
may be sufficient not only to cause pain, but also to burn the skin— 
an effect that should be avoided, as it means the destruction of some 
normal tissue and the consequent production of larger and deeper 
scars. The amount of concentration which different patients and 

1 The space is bo narrow that distilled water is necessary. 



132 GENERAL THERAPEUTICS 

different conditions will tolerate varies considerably. It is desirable 
to use the rays as strong as possible without burning. 

The frequency of the applications and the duration of each vary 
for different conditions and for different individuals. For superficial 
lesions which can he perfectly exsanguinated, half-hour exposures are 
often sufficient. For deep-seated lesions from one to two hour stances 
may he necessary. On each area the treatment is repeated, when 
necessary, as soon as the reaction has subsided, which it does usually 
in from one to two weeks. 

Following each treatment an inflammatory reaction occurs in from 
six to twenty-four hours, varying in degree, according to the intensity 
and duration of the treatment, from a simple erythema to a vesicular 
or bullous dermatitis, which is sharply limited to the area to which the 
light was applied, though when the reaction extends at all below the 
surface there is a surrounding narrow /one of edema. The outline of 
the area of reaction thus affords a ready test of the accuracy with which 
the compressor and light were kept in position during the treatment. 
The vesicles and bullae dry and form crusts, which ultimately fall, 
leaving only the Dew-forming epidermis. The process requires as a rule 
from eight to twelve days. The inflammation produced by the light 
causes no necrosis and no destruction of normal tissue, all of which is 
conserved. Hence the inconspicuous scars produced and the value 
of the treatment from a cosmetic point of view. Moreover, the light 
may be applied freely not only to the morbid area, but also to the 
apparently normal tissue surrounding it, thus insuring destruction of 
advancing pathological processes which cannot be recognized clinically. 
In the normal skin, the reaction on subsiding is followed usually by 
more or less pigmentation, which usually disappears in ten days or two 
weeks. Another effect of the light upon normal skin is to produce a 
slight dilatation of the superficial vessels, which may persist for six 
months or more. The sole clinical manifestation of this condition is 
the readiness with which slight external irritation produces an ery- 
thema of the part. 

The success of the treatment depends largely upon the care with 
which the technique is carried out in all details. It is especially impor- 
tant that the lenses, both of the condenser systems and of the compres- 
sors, be kept absolutely clean. The latter should be cleansed with 
antiseptic solutions after each treatment. The distilled water in the 
chambers of the condensers should be changed often enough to keep 
it free from particles of dust or dirt, and air-bubbles should not be 
allowed to collect on the lenses. 

Though the light treatment has been used most successfully in the 
treatment of lupus vulgaris and other forms of cutaneous tuberculosis, 
it is of value in the treatment also of lupus erythematosus, alopecia 
areata, rosacea, vascular nevi, and some chronic inflammatory cuta- 
neous diseases of circumscribed areas. The special technique appro- 
priate for each of these conditions is considered with the general treat- 
ment of each. Phototherapy is limited in its applicability by the fact 



RADIUM 133 

thai the rays can penetrate exsanguinated ti ue only, and thi> hut to 
;i limited depth. The area treated ;it one time is small, averaging less 
than an inch in diameter. Consequently, when the disorder to be 
treated is extensive, the method as now applied is both tediou and 
expensive. 

Numerous lamps have been invented in the effort to produce one 
with which more rapid results can be obtained and with less expense. 
They may roughly be divided into two classes: 

In the first class, of which the Lortet-Genoud and the London Hos- 
pital lamps are the best-known examples, the source of light can be 
brought within two inches of the region to be treated, the need of a 
condenser being thus done away with. The patient is protected from 
the light by a hollow shield, in the centre of which are two rock-crystal 
lenses, front and back, between which cold water constantly circulates 
and absorbs the heat-rays. The part to be treated is exsanguinated by 
pressing it firmly on the face of the front lens. An arc light is em- 
ployed having carbon electrodes, an amperage of 10 or 12, and a voltage 
of ."),"). These lamps are in some respects more convenient and less 
expensive to use than even the Finsen-Reyn lamp, and give good 
results in superficial lesions, but the light from them has not the pene- 
trating power of that given by lamps which have a series of condensers 
and employ arc lights with higher amperage. 

Lamps of the second class, of which there are many, are constructed 
with the aim of furnishing ultra-violet rays in quantity. For this pur- 
pose iron or other metal electrodes, or the high-tension condenser 
spark, have been used. These lamps are small, convenient, of low 
amperage (1 to 4), and therefore less expensive to install and to main- 
tain. Some of them are powerful in destroying surface-cultures of 
bacteria and in exciting inflammation on the surface of the skin. As 
they depend for these effects upon the ultra-violet rays, which are 
absorbed by the uppermost layers of the epidermis, they have no in- 
fluence upon lesions situated at all deeply in the skin. 

Radium. 1 — The first radio-active substances to be isolated were 
Becquerel-rays, from uranium salts, in 1896. In 1S9S, Madame Curie 
and M. Schmidt independently discovered similar rays in thorium. 
In I !)()(), Professor and Madame Curie discovered two new bodies, 
radium and polonium, the latter being much weaker than the former. 
In the same year actinium was discovered by Debierne, and in 1 * M ) 1 
radio-thorium was discovered by Ramsay and Ilahn. 

Of these various radio-active substances, radium is the one chiefly 
employed in a therapeutic way. The strength of radium salt is deter- 
mined by its power of ionization. Taking uranium as the unit of meas- 
urement, radium possesses an activity of about 2,000,000. Radium- 
bromid is a well-defined salt from which all other salts carbon- 
ate, sulphate, nitrate, stearate are prepared. The bromid, chlorid, 
and nitrate are soluble, and the sulphate and carbonate insoluble. 

Wickhara and Degrais: Radiotherapy. Translation by Dot.-, L912. (To this work 
the author is muoh indebted.) 



134 GENERAL THERAPEUTICS 

The sulphates are those employed with varnish, either on metal or 
cloth, for therapeutic purposes. As a rule, the radium salt is mixed 
with a barium salt in the proportion of one to four, which results in a 
preparation having a radio-activity of 500,000. 

From radium at least three distinct kinds of rays are evolved, the 
principal ones being the Alpha, Beta, and Gamma. The Alpha rays 
constitute the major portion, about 90 per cent. They are readily 
absorbed, may be deflected by a magnet, and have only slight penetrat- 
ing power, a thin layer of metal or rubber being sufficient to intercept 
them; and therapeutically they induce a dermatitis. 

In the Beta group several varieties relative to penetrating power 
occur, some of which arc comparatively soft, others hard. Some of 
these rays have great penetrating qualities and may be detected 
through •") nuns, of lead. It is possible also to influence these rays 
with a magnet. 

The Gamma rays closely resemble x-rays. They cannot be deflected 
and they have marked penetrating power. They are able to traverse 
as much as 10 cms. of lead, which is much greater than the penetrating 
power of .r-rays. They pass through the bony skeleton without pro- 
ducing a trace on the fluoroscopic screen. 

The varying penetrating qualities of the rays are taken advantage 
of therapeutically, and filters may be used to eliminate the more super- 
ficial pays when desired. A screen of cotton-wool or of aluminum will 
intercept the Alpha pays. Screens of greater density are required for 
the others. In the free state the Alpha rays constitute 90 per cent, of 
the total radiation, the Beta 9 and the (lamina 1. This proportion 
is changed when the salt i> mixed with varnish for therapeutic pur- 
poses, as the varnish acts as a screen. From such a source the Alpha 
rays are reduced to from 1 to 10 per cent.; the Beta rays predominate, 
in the proportion of from 80 to 90 per cent. ; and the Gamma have a 
percentage of from 1 to 10; so that in treatment the activity emitted 
is largely in the form of Beta rays. 

The method of employment is either to have the radium salt in 
tubes or spread on metallic plates or pieces of linen and held in posi- 
tion by a special varnish. The tube is made of glass and sealed, and 
is then enclosed in a second tube of gold, silver, or platinum, of a thick- 
ness depending upon the intensity of the radio-activity desired, the 
tube thus acting as a filter. It is possible by this form of apparatus 
to treat in cavitis, as in the mouth, and also to insert the tubes into 
tumors. The metal plates upon which the radium salt is held in posi- 
tion by a varnish are made in various shapes, such as flat, concave, 
convex, cylindrical, spherical, or laminated, to fit the various por- 
tions of the surface or cavity to be treated. In those having a linen 
base the shape naturally is readily changed. In either case there is 
presented a perfectly smooth, slightly shiny surface, of brownish color, 
due to particles of radium which show through the transparent varnish. 
Their color, however, varies with age from yellowish early to brown or 
black later. 



LIQUID AIR AND SOLIDIFIED CARBON DIOXID 135 

The reactions produced by radium arc similar to those induced by 

x-rays. Varying grades of dermatitis, including superficial and deep 
ulceration, may follow its use. Radium is of special value in t he treat- 
ment of nevi. It Is also employed in several diseases where ar-rays 
are valuable, such as epithelioma, keloid, and chronic inflammations. 
Liquid Air and Solidified Carbon Dioxid. 1 — These methods of treat- 
ment have been developed within recent years. Their action is essen- 
tially a caustic one, induced by intense refrigeration. Liquid air is 
difficult to obtain and hence is not always available. It is kept in 
double-walled glass containers, which are not sealed, as evaporation 
must be allowed to occur to prevent explosion. It is applied to the 
skin on cotton swabs with moderate pressure. The tissue is imme- 
diately frozen white, and is very hard and depressed. Within a short 
period the circulation is resumed, at which time some pain is experi- 
enced. Swelling, with redness and bullous formation, soon follows. 
Later changes depend upon the amount of destruction induced. Car- 
bon dioxid snow, suggested by Pusey, is more convenient, readily 
obtained, and fulfills much the same requirements. It is only about 
one-half ascold. It is obtained from the ordinary liquid carbon-dioxid 
containers, and when the snow is collected it may be moulded into the 
required shape and applied. These agents are used in the treatment 
of nevi and benign growths, lupus erythematosus, and small epithe- 
liomata. 

1 Dade, C. T., Trans. Amer. Derm. Assoc, for 1905. Whitehouse, H. H., Jour. Amer. 
Med. Assoc., 1907, xlix, p. 371. Trimble, W. B., Jour. Cut. Dis., 1907, xxv, p. 409; 
\. u York Med. Record, July 8, 1905. Pusey, W. A., Jour. Amer. Med. Assoc, 1907, 
xlix, 16, p. 1354. White, C. J., Jour. Cut, Dis., 1908, xxvi, p. 505. Heidingsfeld, M. L., 
Ohio Med. Jour., 1908, iv, p. 466. Zeisler, J., Zeitschrift, 1908, xv, p. 409, and Jour. 
Cut. Dis., 1909, xxvii, p. 32. 



CLASSIFICATION. 



The numerous attempts which have been made to classify diseases 
of the skin according to their nature and relations have been in re- 
sponse to the generally recognized demand tor a systematic arrange- 
ment of all scientific facts. As regards dermatology, not only have 
these attempts been numerous and based upon different principles, 
hut the results which they have accomplished have also been in the 
highesl degree divergent. No classification yet devised lias secured 
genera] acceptance. While it is certain that no one system of classi- 
fication has been perfect, and that each has exhibited defects, it is 
equally true that of the large number each has possessed some merit 
of its own. No perfect l\ satisfactory classification of cutaneous dis- 
eases can be made until the knowledge of disease of the skin has been 
greatly enlarged. 

One of the most acceptable of the systems thus far proposed is that 
of Hebra. In it cutaneous disorders are arranged in the following 
nine classes: 

Class l. Disorders of Secretion. 

('lass 2. Hyperemias. 

( Ilass '■'>. Exudations. 

( 'lass I. Hemorrhages. 

( Jlass 5. Hypertrophies. 

Class 6. Atrophies. 

Class 7. New Growths. 

('lass 8. Neuroses. 

Class 9. Parasites. 
Since this classification was devised by Plebra none has been pro- 
posed which compares in ingenuity with the arrangement made by 
Auspitz. The principle of this classification is to place together those 
diseases and groups of diseases which present a clinical unity, the 
general pathological process being the predominant characteristic for 
selection; individual characteristics, such as symptoms, localization, 
and anatomical peculiarities, being brought thus predominantly for- 
ward wdien coinciding w T ith the real nature of the class, the group, or 
the skin-disease in question. 1 Auspitz's nine classes are: 

1. Simple Inflammatory Dermatoses; 2. Angioneurotic Dermato- 
ses; 3. Neurotic Dermatoses; 4. Stasic Dermatoses; 5. Hemorrhagic 
Dermatoses; 6. Idioneuroses; 7. Epidermidoses; 8. Chorioblastoses; 
9. Dermatomyeoses. 

1 System d. Hautkrankheiten. Wien, 1881. 
(136) 



CLASSIFICATIOh 13' 

Under these classes, by the aid of divisions and subdivi ion . an 
elaborate scheme is presented which embraces not only nil cutaneous 
diseases, bul also ;ill pathological processes recognized in the kin. 

The mere presentation of this system has been followed by an advance 
in the nosology of cutaneous medicine more satisfactory" than any 
since the contributions to this subject by Hebra. 

Auspitz's classification, however, is open to various objections on 
the part of the student of dermatology. It is elaborated to the extent 
of placing the names of some diseases in more than one family, and 
hence is confusing to the beginner. It is better adapted to the 
Deeds of the expert than of the student, for it introduces to the study 
rather of morbid processes in the skin than of the complexus of those 
processes which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, 
or pathological; whether it be based on the processes actually occur- 
ring in the skin, or on those deeper factors and forces which operate 
centrifugally upon the skin, and on which that organ depends for all 
its functions and even its existence; whether it proceed etiologically 
from causes which are immediate or those which are remote, it is easy 
to see that, as knowledge in each of these directions enlarges, the exact 
position of any one disease in any given classification must be rendered 
insecure. Never was this observation more suggestive than at this 
day, when the pathogeny of numerous skin-disorders is revealed in 
the light thrown on the subject by the discovery of hitherto unknown 
organisms. 

Several recent writers have contented themselves with an alpha- 
betical indexing of the names of skin diseases as an order useful simply 
for reference. 

The arrangement of titles of diseases of the skin in this treatise is 
a modification of the scheme first proposed by Hebra on the lines recog- 
nized by the American I Hematological Association in its classification 
adopted in 1884. As the arrangement stands today, it should be 
regarded as a mode of grouping diseases for the convenience of the 
student, rather than as an attempt at a scientific classification of dis- 
cuses of the skin. 



DISEASES OF THE SKIN. 

CLASS I. 

HYPEREMIAS AND INFLAMMATIONS. 

ERYTHEMA. 

Erythema denotes redness of the skin. It may be of varying 
shades, from Bright scarlet to a deep bluish-red. In cutaneous 
medicine the term is used, unfortunately, both to describe a symptom 
and to indicate specific dermatoses; in the latter case some qualifying 
term being added. It is usual to divide the erythemas into two main 
groups: one form due to hyperemia, which is usually short-lived and 
induces no changes in the skin; the other form the exudative erythemas, 
accompanied by the changes induced by inflammation. Sharp dis- 
tinctions cannot be drawn between the two kinds, as individual mem- 
bers tend to overlap. 

Erythema Hyperemicum (seu Simplex). — Erythema simplex is a 
coloration of the skin in various shades of redness, diffuse or circum- 
scribed, temporarily disappearing under pressure, the lesions differing 
in size, hue, and shape according to the extent and degree of the hyper- 
emia by which they are induced. 

Simple erythema is seen in the phenomenon known as blushing. 
Ordinarily, this is a purely physiological and transitory hyperemia due 
to emotional causes. ( 'ases occur in which the hyperemia thus induced 
persists for hours, together with palpitation and other evidences of 
circulatory disturbance. Here the erythema is symptomatic of either 
physical or mental disorder. With the former may be classed those 
disorders in which portions of the face remain flushed after eating, 
exercise, exposure to heat, etc. 

I nder idiopathic erythema have been classed the simple forms for 
which no cause is recognized. In many cases, a careful search will 
disclose the disease or condition of which the erythema is but a symp- 
tom. The cause may be found in external irritation too slight and 
transient to produce a dermatitis, in disturbances of the alimentary 
canal, in the nervous irritability of children due to teething, in a drug- 
idiosyncrasy, or in one of many derangements of the general economy. 
Again, the erythema may be a more or less important diagnostic symp- 
tom of graver constitutional diseases, as in the exanthemata and 
t \ phoid fever. The color in simple erythema may vary from a delicate 
pink or rose shade to a dark-reddish line, which may be transitory or 

(139) 



140 HYPEREMIAS AND INFLAMMATIONS 

persistent, may be limited to circumscribed points or macules, or be 
displayed in diffuse, ill-defined areas. The character, duration, and 
distribution of these rashes, when due to simple causes, often depend 
largely upon the peculiarity of the individual. The same source of 
disturbance or irritation may produce different effects on the skin of 
different persons. 

Erythema Traumaticum occurs as the result of friction, rubbing, 
pressure, scratching, or similar external contacts. It is observed, for 
example, in the part pressed by the pad of a truss, and on the sides of 
the nose, where pressure is exerted by eyeglasses. Traumatic hyper- 
emias are readily converted into exudative affections if the traumatism 
be long continued. Intermittent pressure upon the skin promotes 
restoration of the vascular equilibrium, and the integument responds 
to the demands made upon it by increasing in thickness. Continuous 
pressure, on the contrary, admits of no such restoration, and the 
tissue finally becomes thinner and a certain degree of atrophy follows. 
Inflammation, resulting in ulceration, may finally supervene. 

Erythema Caloricum is a transitory redness of the skin-surface in- 
duced by extremes of heat and cold. In the erythema induced by 
-i ilar heal erythema solare) there is frequently also increased pig- 
mentation of the surface, a- in the production of freckles and tan in 
persons whose skins are reddened by the sun. The darker, brownish, and 
chocolate-colored stains of the hands and face are thus induced. The 
effects of light are often commingled with those of heat in cases of inso- 
lation. The well-know n results of exposure to the rays from the 
Finsen lamp, where, in consequence of the cooling of the medium, no 
heat-rays arc effect i\ e, include erythema and even active inflammation. 

Erythema Venenatum denotes that form of erythema induced by a 
number of external toxic substances, such as dyes and vegetable 
poisons. Among these may be mentioned cantharides, capsicum, 
mustard, anilin, chloroform, ether, arsenic, several dyes used in com- 
merce', and some of the essential oils. 

Erythema Gangrenosum is the title employed to designate cases in 
which gangrene follows in areas beginning as simple erythema. There 
are probably two classes of cases. The first and commonest are feigned 
eruptions. Two cases of this variety were described by T. C. Fox. Gal- 
loway reports one of the other (idiopathic) variety. 1 His patient, a 
young woman, suffered for twelve or fifteen years from a general and 
almost constant congestion of the whole cutaneous surface. The 
slightest injury produced nodules, which were followed by necrosis 
and ulceration. The patient died from what appeared to be a spon- 
taneous gangrene of the breast and trunk. 

Erythema Lseve is an obsolete term formerly employed to designate 
the shining redness of the skin in edema of the lower extremities. 

Erythema Paratrimma was a term formerly employed to describe 
the lurid redness which precedes the formation of a bedsore. 

1 Brit. Jour. Derm., 1903, xv, pp. 235-249, inc. 



SYMPTOMATIC ERYTHEMA I II 

Erythema Fugax is the term applied to a transitory redness of the 
skin, usually occurring in small areas, which appears and disappears 
very much as <!<> the lesions of urticaria. It^ true nature appears 
to be an urticarial erythema. 

Erythema Urticans is a variety of urticaria. 

Erythema Ab Igne. This form of erythema has been described 
chiefly by English and American authors. It occurs, as a rule, on the 
anterior surfaces of the legs, hut may also occur on other parts of the 
body exposed to undue heat. The lesions occur in annular and gyrate 
patches. Ilartzell 1 describes the condition as a reticulate erythema. 
The color in the patches varies from a light to a deep red, or even pur- 
plish, tint, and often permanent pigmentation results as the erythema 
subsides. The disease occurs in cooks, stokers, and other persons 
exposing portions of the body to the direct action of heat, and, accord- 
ing to Ilartzell, in persons whose health is below the normal standard, 
either as the result of previous illness, alcoholism, or old age. While, 
as a rule, this condition is produced by the direct action of heat from 
stoves, furnaces, and the like, cases are recorded which were induced 
by such things as a hot-water bag. A study of the sections in two 
of Hart/ell's cases showed that the disease is really an inflammatory 
one, and not a simple staining of the skin with the blood pigments. 
The epidermis showed a moderate degree of parakeratosis and a slight 
broadening of the rete layer, and there were a few scattered poly- 
morphonuclear leukocytes lying between the cells of the granular layer. 
In the corium a moderate amount of cellular exudate, particularly in 
the vicinity of blood-vessels and about the coil-glands, was noted. 
All sections showed deposits of brown, granular pigment in the basal 
cells of the rete mucosum. 

Symptomatic Erythema may be of either active or passive type. 
Numerous physiological and pathological causes operating upon the 
skin at large are capable of producing active symptomatic hyperemia 
of the skin. The redness may be generally diffused, or occur in sur- 
face niottlings or markings of various sizes and shapes. Several severe 
constitutional maladies betray their morbid influence on the central 
nervous system by an erythema. A lurid erythema of the axillary or 
inguinal region may precede by several days the eruption of confluent 
variola. Cholera, cerebro-spinal meningitis, diphtheria, and enteric 
and other fevers are thus at times accompanied, preceded or followed 
b\ rashes. A knowledge of these rashes is of the utmost importance. 
Children are attacked comparatively frequently with symptomatic 
erythemas of a scarlatiniform and morbilliform type. Vaccination 
may also be followed in from one to eight or nine days by a macular 
or more diffuse erythema of the trunk and extremities, usually accom- 
panied by some febrile reaction. The importance of these erythemas 
lies in their differentiation from the contagious ones which they 
resemble. 

1 .lour. Cut. Dis., 1912, xxx. |». 461. 



142 



HYPEREMIAS AND INFLAMMATIONS 



Roseola Infantilis is sometimes described as a distinct affection, in 

which there are fever and constitutional disturbance lasting for a few 
hours or even a few days. The exanthein varies greatly in extent and 
distribution. It is usually macular or punctate, hut may he finely 
papular. It is most common on the trunk, hut may appear on other 
parts of the body. It may closely simulate scarlatina or measles. 
This eruption is generally a manifestation of some systemic or local 
disorder. 

Fig. 34 




Toxic erythema. 



Symptomatic Passive Erythema is usually characterized by a cyan- 
otic, purplish or darker hue of the integument, resulting largely from 
accumulation in excess of carbon dioxid in the blood. The tem- 
perature of such skins is either normal or below the normal standard, 
as in those cases in which gangrene ensues. There are many condi- 
tions in which these symptoms are noted, including derangement of 
the blood-vessels from imperfect innervation, direct pressure, or disease 
of the heart or vascular walls. 

These erythemas may be either circumscribed in area or generalized. 



TREATMENT OF ERYTHEMA 143 

The term livedo is applied to circumscribed regions of passive hyper- 
emia. 'Flic nose, cheeks, fingers or toes may thus be affected, as in 
erythema pernio. The so-called symmetrical gangrene of the fingers 
belongs to the same category. Cardiac cyanosis or morbus caruleus 
is a name given to a generalized dark-blue discoloration of the entire 
surface, due to a continued patency of the foramen ovale. 

Erythema of Jacquet.- r l nis is an eruption of the napkin region of 
infants, whose importance has recently been emphasized by Adamson, 1 
the following- description being largely taken from his work. On 
account of a close resemblance in certain cases to congenital syphilis, 
the disease should be recognized. The cases are divided into four 
groups: (1) simple erythemas; (2) erythemato-vesicular or erosive 
forms; (3) papular or post-erosive forms; (4) ulcerating forms. The 
lesions are situated on the convex surfaces, between the flexors, and 
may occupy or be situated upon the inner parts of the thighs, the 
perineum, and genitals, or extend over the buttocks, the posterior 
surfaces of the thighs, the lower part of the abdomen, and upon the 
calves and heels. The erythema is described as having a deep-red and 
shining appearance, and its selection of convex areas, leaving the 
flexors, is striking. In the more severe cases, the three subsequent 
subdivisions occur, consisting of vesicles, papules, or ulcerations. The 
distribution of the eruption upon the prominent convex surfaces sug- 
gests local irritation by wet or soiled napkins as a factor in these erup- 
tions. Adamson suggests a disturbance in the vasomotor system as a 
predisposing factor. In a patient recently seen by the author, mal- 
nutrition played an important role in the question. This was a typical 
case, and strongly suggested congenital syphilis. It is said that in 
children's clinics these cases are far from uncommon. There is no 
evidence that subjective sensations are present. 

Pathology. — The histological changes described by Ferrand and 
concurred in by Adamson consist of a spongioid transformation of 
the prickle-cell layer, desiccation, acanthosis, parakeratosis, cell- 
exudation, and dilatation of the vessels in the papillary layer of the 
corium. 

Diagnosis. — The important question is the recognition of the fact 
that the disease is not a manifestation of syphilis. The absence of 
lesions about the mouth and lips, and other signs of congenital syphilis, 
readily settles the question. 

The diagnosis of simple erythema is usually not difficult, since with- 
out exudation there is an absence of all other elementary or secondary 
lesions of the skin. The chief point or difficulty lies in the establish- 
ment of a cause. 

Treatment. In the management of the simple forms of erythema, 
the removal of the cause is the chief object. Alkaline washes, boric- 
acid solution, zinc-oxid and liquor-calcis lotions, or dilute black-wash, 
may be followed by the application of a dusting-powder; or the last 

' Brit. Jour. Derm., 1909, xxi, pp. 41 17, inc. 



144 HYPEREMIAS AND INFLAMMATIONS 

may suffice. Exclusion of irritants, such as washing the parts with 
soap and water, is advisable. 

Erythema Scarlatiniforme. — Synonyms: Scarlatinoid Erythema, 
Desquamative Scarlatiniform Erythema, Scarlatinoid^, Erythema 
Punctatum, Roseola Scarlatiniforme, "Scarlet Hash," Dermatitis 
Scarlatiniformis Recidivans. Fr., Erytheme infectueiix. 

Definition. — Erythema scarlatiniforme indicates an eruption arising 
from several causes and varying considerably in character, hut having 
a tendency to simulate the rash of scarlatina. This condition has 
been described as an idiopathic disease, hut it is very often demon- 
strated to he a symptom only of other disorders. Besnier, Brocq, 
and other French authors describe an erytheme scarlatinotde, which 
is acute in type, and which is always secondary to other infectious 
diseases, to autotoxemia, or to medicinal or food toxemia; and an 
erythdme scarlatiniforme desquamatif, which is subacute in type, and 
which may he idiopathic secondary to other infections diseases, or 
produced artificially by drugs. 

Symptoms. In the acute type, which is the more common of the 
two forms, the ra>h may he preceded by a day or two of fever and other 
evidences of constitutional disturbance, frequently lapsing with the 
occurrence of the eruption, or it may appear suddenly without pre- 
monitory symptoms. The exanthem spreads rapidly, and in a few 
hours, or at most in two or three days, reaches its full development. 
The eruption is commonly universal, or at least generalized, but may 
be more limited in distribution. The rash may be punetiform, macular, 
or diffuse, and the color may be any of the shades of red, but it is usually 
a bright scarlet. In some instances, the appearances are those of a 
typical scarlatinal rash. There are usually some fever (100° to 103° 
F.), malaise, and other constitutional disturbances, that may vary 
greatly in intensity, depending upon the cause of the disease in that 
particular instance. The mucous membrane of the mouth, the tongue, 
and the fauces may be reddened or be denuded of epithelium, but is 
not swollen. The nails and hair may be shed, but only in exceptional 
cases. Desquamation usually begins in from two to six days, some- 
times before the disappearance of the rash; and it may even occur on 
surfaces which had not perceptibly been reddened. The scales are 
usually furfuraceous, but they may be large and abundant. In rare 
instances, the entire epidermis of the hand may be shed in glove-like 
form. Complete involution may require from a few days to several 
weeks. Rarely, the process terminates in a persistent exfoliative 
dermatitis. Recurrences are common, but in some instances may be 
prevented by the discovery of the active cause. 

The subacute forms of erythema scarlatiniforme differ from those 
described above in that constitutional disturbances are less, the rash 
has a greater tendency to be universal, and, together with the desqua- 
mation, may persist for weeks or months, recurrences being common. 
x\t times they are so frequent as to make the condition practically 
continuous and clinically indistinguishable from the milder forms of 
dermatitis exfoliativa. 






SHEDDING OF Till-: SKI \ 145 

Etiology. Idiosyncrasy is a mosl important factor In the etiology 
of those forms of erythema which appear in certain predisposed Indi- 
viduals as a result of causes totally insufficient to produce the jame 
phenomena in most persons; as, for example, in persons exceptionally 
susceptible to quinin administered by the mouth. The exciting factor- 
is usually if not always some form of toxemia. Among many causes 
reported are infectious diseases, septicemic conditions, toxemias of 
varied origin, renal disease, peritonitis, rheumatism, ague in children, 
gonorrhea, abscess, empyema, serums, tuberculin injections, sewer- 
gas poisoning (Crocker), certain articles of food, and many drugs, 
the most important among the latter being mercurial inunctions. 
The author has seen a typical case following the application of iodo- 
form, and this case had recurrences without renewal of the original 
cause. 

Diagnosis. — Jt is important to distinguish this rash from that of 
scarlet fever. Commonly, the diagnosis is not difficult, but occa- 
sionally the greatest difficulty is encountered. As a rule, in erythema 
scarlatiniforme the constitutional symptoms are slight; the rash 
appears rapidly, beginning irregularly on any part of the body; the 
lesions are exclusively cutaneous; desquamation begins early (in from 
two to three days), and is extensive; the fauces, though red, are not 
swollen; and there is absence of the "strawberry tongue," of leuko- 
cytosis, and of all history of contagion. Occasionally, the rash may 
resemble that of measles or rotheln; but the history of the case and 
the absence of other symptoms peculiar to these affections should 
make the diagnosis clear. As a rule, an examination of the rash alone 
is insufficient, and a diagnosis of erythema scarlatiniforme should not 
be made until other exanthemata have been considered and excluded. 

Treatment depends entirely on the underlying cause or condition. 
Toxins present should be eliminated as rapidly as possible. The 
eruption itself rarely calls for treatment. If there be itching or burn- 
ing sensations, a simple dusting-powder, with or without an anti- 
pruritic or a soothing lotion or ointment, may be used to make the 
patient more comfortable. In extensive cases, the unguentum aqua 
rosae gives much relief. In the subacute recurrent cases, careful search 
should be made in the alimentary tract, and good results have been 
obtained by so regulating the diet as to promote free elimination and 
prevent the accumulation of waste products. 

Prognosis. As a rule, the eruption disappears promptly and the 
general health of the patient is unaffected. Recurrences are frequent, 
and in some cases terminate in a more or less persistent exfoliative 
dermatitis. 

Shedding of the Skin {Deciduous Skin, Keratolysis). Cases are 
reported of individuals whose skin is shed periodically, like that of a 
serpent. Dr. Hyde had the opportunity of observing the symptoms 
in the case reported by Frank and Sanford 1 during several of the 

1 \nirr. .lour. Med. Sci., August, L891. 
10 



14G HYPEREMIAS AND INFLAMMATIONS 

periods in which the patient's skin was exfoliated. The subject 
was thirty-three years of age, well formed and apparently in perfect 
health. No cause for the skin shedding could be found. He stated 
that ever since he could remember, and certainly since he was eight 
years old, he had had peculiar symptoms, which began between 
3 and ( .) p.m. of July 24 of each year. lie would suddenly experience 
a feeling of lassitude or weakness, followed by muscular tremors, 
nausea, and vomiting, with rapid rise in temperature. Accompany- 
ing these symptoms, the mucous membranes were hyperemic, and 
the skin became hot, dry, and destitute of perspiration. After three 
or four hour-, the acute symptoms began to subside, hut the skin 
remained red for thirty-six hour- longer. The shedding of the skin 
began usually on the second or third day, and was completed in from 
three to ten days. 'Hie mucous membrane of the tongue and mouth 
exfoliated on the third day. The epidermis was removed from the 
trunk and arms in large sheets on the sixth day, and from the remainder 
of the body, except the hand- and feet, within the next three days. 
Complete casts of the hands and feet were shed on the seventeenth 
day, and the nails all came oil' within a month from the beginning of 
his illness. 

This case was observed the following year and reported by Sligh. 1 
His report confirms the facts above recorded. Similar cases are 
reported by Stelwagon, 2 Stone, ; and others. Cases of constant exfoli- 
ation of the skin rather than periodic have occurred. These are rare, 
and arc described under the term keratolysis exfoliativa <'(>iuj< nita. 

Erythema Pernio. Synonyms: Pernio, "Chilblains." (Jer., Frost- 
beule. Ft., Engelure. 

Definition. Erythema pernio occurs in persons having a feeble 
circulation, and on parts of the body which are remote from the heart 
(fingers, toes, ear>, and nose). It occurs usually in the young and the 
very old. Permin 4 calls attention to its frequent occurrence in the 
tuberculous. The redness is either of a light or dusky shade; is 
accompanied by tenderness, itching or burning sensations, especially 
when the part is brought near an artificial source of heat; and may 
be the origin of exudative and other affections of the skin, though 
the ulceration and sloughing which occur in extreme cases are really 
the results of freezing the organs, rather than of simple exposure 
to cold when the circulation is impaired. The disorder recurs in cold 
weather, clearing up in the warmer seasons. The impaired vitality 
of the skin in these cases, due to vascular disturbance, and the edema 
present render the skin liable to severe injury from small cause. 

Diagnosis. — The diagnosis is readily made when one observes that 
the redness disappears on pressure, and also that the parts are actually 

1 Internat. Med. Mag., 1893, p. 463 (two plates). 

2 Diseases of the Skin, 5th Ed., p. 143. 

3 Jour. Amer. Med. Assoc., September 1, 1900, p. 557 (two cuts). 

4 Hospitalstidende, 1903, xviii, Copenhagen; abstr. Brit. Jour. Derm., 1903, xv, p. 
376, 



ERYTHEMA INTERTRIGO I 1/ 

cool rather than hot, the coolness being appreciable by the touch. 
Not rarelj the involved surfaces are both cool and moistened with 
sweat. Pernio may closely resemble an early stage of lupus erythema- 
tosus, bul the latter does not vary regularly with the seasons, as does 

pernio, which usually disappears in summer and reappears in winter. 

The two conditions arc at times related, as individuals are seen with 
pernio of the hands and feet and lupus erythematosus of the face. 
Cases are recorded in which the site of a recurring pernio has become 
the seat of a typical lupus erythematosus. 

Treatment.— Tin* treatment of pernio should be directed to the 
improvement of the circulation and general health. Warmer clothing 
to protect the affected parts, together with active exercise, may do 
much to prevent the recurrence of the disease. Fowler's solution is 
considered a prophylactic if given in small doses at the beginning of 
cold weather. The local treatment is by brisk friction and stimulating- 
lotions, such as camphorated soap-liniment; acetous, spirituous, and 
vinous lotions; or the use of the ordinary bay rum of the shops. After- 
ward the part should be painted with a 50 per cent, solution of ichthyol, 
well dusted with talcum powder, and bandaged or WTapped in cotton. 
The severer forms of the disease are considered as a dermatitis calorica. 

Erythema Intertrigo. — Synonyms: Intertrigo, Eczema Intertrigo, 
Chafing. Fr.j Erytheme intertrigo. 

Definition. — Erythema intertrigo is a hyperemic condition of those 
cutaneous and muco-cntaneous surfaces which are in constant appo- 
sition, and between which there is a hypersecretion and retention of 
sweat. 

Symptoms. — The erythema is limited to parts of the integument which 
lie in contact with each other. The sites of such contact in the human 
body are the axilhe, the groins, the cleft between the nates, the inter- 
mammary and inframammary spaces in women, the superior and 
inner faces of the thighs, the scroto-femoral and the labio-femoral clefts 
in the sexes respectively, the flexures of the joints, and in especially 
obese individuals all those parts where the integument is thrown into 
fleshy folds, as about the neck of infants, and even over the crest of the 
ilium in fat subjects. In these localities, the disorder, beginning as 
an erythema traumaticum, proceeds by its irritative effects to stimu- 
late the secretion of sweat, which is freely poured out between the 
adjacent folds of the skin and may there be imprisoned temporarily. 
The surface, heated and reddened, is also somewhat macerated by the 
effused perspiration, and the latter, when chemically altered, as it is 
frequently under these circumstances, adds still further to the original 
disorder. 'Flic ground is thus well prepared for an exudative process, 
which not infrequently supervenes in the form of a dermatitis; but the 
disorder may be limited to mere hyperemia with hyperidrosis, and dis- 
appear before the supervention of actual inflammation. Superficial 
abrasions of the macerated epidermis occur, and one such abrasion 
is always especially significant. It is the linear and superficial exco- 
riation which marks the line of deepest contact of the two apposed 



148 HYPEREMIAS AND INFLAMMATIONS 

surfaces of the skin at the bottom of the angle formed by the two. An 
offensive odor usually proceeds from the part, in consequence of the 

chemical changes in the secreted fhiid. The secretions of an inter- 
trigo stain hut do not stiffen the linen of the patient, and they thus 
differ from the serous fluid poured out in an exudative dermatitis. 
The subjective sensations arc those of heat and tenderness. 

Etiology. The disease is chiefly induced by heat, friction, and 
moisture. These causes occasionally cooperate. The heat may be 
merely that of the natural temperature of the body, or it may be in- 
creased by that due to season or climate. The friction may be merely 
that originating between the surfaces in apposition, or may be increased 
by clothing or other articles worn next to the skin. The moisture 
which produces maceration of the epidermis is the sweat-secretion, this 
being stimulated by heat and friction. As aggravating causes may be 
named physiological excretions and secretions retained in contact with 
the surfaces affected with an intertrigo. Thus, the i'vws, the urine, 
the milk in nursing women, retained lochia!, menstrual, and similar 
discharges, and glycosuria are all efficient in this regard, and are par- 
ticularly likely to induce that form of dermatitis to which the inter- 
trigo then plays a subordinate part. Fleshy and gouty persons chiefly 
suffer from these accidents. 

Diagnosis. 'Flic recognition of a simple erythema intertrigo is a 
matter of no difficulty if regard he had to the exciting and aggravating 
causes enumerated above and to the special localities in which such 
hyperemia generally originates. If an eczema or a dermatitis super- 
vene, the fact will appear from increased subjective sensations (usually 
severe itching), from an infiltration of the affected integument, and 
from the appearance of those lesions and discharges which are signifi- 
cant of these forms of inflammation of the skin. It must be remem- 
bered that transition from a simple erythema to a dermatitis of these 
regions is of frequent occurrence. Erythema intertrigo may occur 
as a mild form of dermatitis seborrheica. The disease is to be differ- 
entiated, also, from tinea cruris, the latter being more inflammatory, 
exhibiting scaling, and under microscopic examination of the scales an 
epidermophyton fungus is found. In babies, congenital syphilis and 
the erythema of Jacquet are to be differentiated. The deeper involve- 
ment by both of the latter disorders, as a rule, and concomitant symp- 
toms in one of them, serve to differentiate them. 

Treatment. — Intertrigo is an exceedingly common affection of the 
skin, and it occasionally proves of great annoyance to those suffering 
from it. Gouty patients always require limitation of the diet, and 
often also medication with alkalies and mercurial cathartics. 

The affected surfaces should be cleansed gently by ablution with 
soap and warm water, and the offensive odor of the secretions remedied 
by the addition to the water of a weak solution of formalin, of phenol, 
or of the dilute liquor sodas chlorinatse. The parts are then to be 
carefully dried with a freshly laundered towel or soft gauze, and after- 
ward one of the dusting-powders very thoroughly applied. To be of 



ERYTHEMA MULTIFORME I 19 

service, these powders must be Impalpable, and, if compounded by a 
druggist, be sifted through fine silk bolting-cloth. The articles chiefly 
used for this purpose are zinc stearate with acetanilid, bismul h, 3tarch, 
zinc oxid, French chalk, lycopodium, or, when an antipruritic effecl 
is desired, camphor. Combinations of several of these arc a1 times 
effective. The formula of Mc( 1 all Anderson is highly esteemed: 



J\ — Zinci oxid. pulv., 5ss; 16 

( 'amphora' pulv., 5jss; 6 

Amyli pulv., 5J> 32 
Sig. — Anderson's dust ing-powder. 



M. 



For the purpose of absorbing excessive perspiration, magnesium 
carbonate is the most effective of all the powders. 

The following- is the formula for a dusting-powder recommended by 
Klammann: 1 



1$ — Talc, venet. pulv., 5v; 20 

Acid, salicyl., gr. iij; 

Magnes. ust. subtil, pulv., 5jss; 6 

Sig. — Dusting-powder. 



20 
M. 



Finely bolted starch answers well alone or in combination with some 
of the other articles above named. Unna's salve-muslins and pastes 
will be found effectual and neat applications in many forms of inter- 
trigo. 

The affected surfaces of the skin must also be separated in order to 
prevent further friction. A thin strip of lint, gauze, antiseptic cotton, 
or medicated wool may be used for this purpose, and must be inserted 
as far as the deeper portions of the cleft in which the secretion chiefly 
forms. Occasionally, it will be found useful to anoint this absorbent 
layer with borated cold-cream salve or with vaselin. Where an 
astringent effect is desired, lycopodium or other dusting-powder may 
he compounded with tannin, alum, or similar substances. The list of 
lotions also at times may be consulted with advantage. Thus, cologne- 
water, saturated aqueous solutions of pyoktanin blue, weak spirit 
lotions containing tannin, aromatic wine, or zinc oxid and lime-water 
may each be serviceable. Lastly, equal parts of lime-water and olive-oil, 
spread thickly upon linen, will possibly give more relief than other 
articles named, the chief objection to it being the consequent soiling 
of the patient's linen. 

Erythema Multiforme. 2 — Synonyms: Erythema Exudativum Multi- 
forme. Fr., Erytheme polymorphe. 

Definition. — Erythema multiforme is an acute, inflammatory, exuda- 
tive disease, characterized by crimson-red or purplish-red macules, 
pa I >iiles, or tubercles, with the occasional appearance of vesicles or 
pustules, the lesions being variously grouped or isolated, frequently 

1 Hebam. Kalend., Obstet. Gazette, March, L882. 

1 Symposium on the Toxic Dermatoses, .Jour. Cut. Dis., L912, \\\. pp. 11!) 167, inc. 
Discussion on Erythema Multiforme by members of the Royal Society of Medicine, 
London, Brit. Jour. Derm., 1912, xxiv, pp. 429 445, inc. 



150 



HYPEREMIAS AND INFLAMMATIONS 



accompanied by general symptoms, and usually due to a systemic 
disturbance. A clear conception of this remarkable disorder may he 
gained by studying it first as it appears in mild form, with super- 
ficial lesions, usually situated on particular areas of the cutaneous 
surface, prone to recurrence, practically limited to the skin in its 
manifestations, and of unknown etiology; second, as a symptomatic 
erythema of several diseases of known infectious nature; third, as a 
surface expression of visceral disease; fourth, as cutaneous manifesta- 
tions produced by the ingestion of many different drugs, and the injec- 
tion of serums; and, finally, as a group of cases presenting the erythema 
multiforme complex, hut of such severe grade that some difficulty is 
experienced in distinguishing them from certain forms of pemphigus. 

I'm;. 35 




Erythema multiforme. 



Symptoms. — The most common lesions are edematous looking 
macules, flattened papules, and large, flat nodosities. Vesicles and 
bulla? develop in some cases. While multiformity is the rule, one 
type of lesion usually predominates in each case. The eruption is 
nearly always symmetrical, and is usually found on the dorsum of the 
hands and feet, the legs and forearms, and often on the face and neck. 
It occurs exceptionally on other parts of the body, and rarely upon the 
mucous membrane of the mouth, nose, and conjunctiva. It has been 
seen on the sclera. 

From the beginning, the lesions are more or less flat, elevated, and 
edematous. The eruption, which is generally recognized in well- 
defined patches, usually begins with pinhead- to finger-nail-sized 
macules of a darkish-, bluish- or purplish-red shade, that lose their 
color upon pressure, and in the course of some hours exhibit tume- 
faction in various degrees, thus producing the papules, tubercles, and 
nodes alreadv mentioned. In some cases there is a tendency to a 



PLATE II 




Erythema Multiforme, Cireinate Type. 



ERYTHEM I MULTIFORME 



l.'il 



Battening and widening of the lesions to the point where they clo < I. 
re emble ;i floridly tinted condyloma. The disease may persi I for 



Fig. 36 




Erythema multiforme. 
Fig. 37 




Erythema multiforme) iris lesions. (Fordyce.) 



152 



HYPEREMIAS AM) I XELAM MATIOXS 



but a few days, hut in severe cases it may last for several weeks or 
months. The average simple ease runs its course in from two to four 
weeks. Recurrent attacks through a period of years arc not uncom- 
mon, and these are likely to appear in the spring and autumn. At the 
height of the exudative process, there is usually an efflux of the color- 
ing matter of the blood into the skin which is the site of the several 
lesions; and thus are produced the singular shades of reddish-black, 
purple and red, blue and red, yellow and orange, and black and blue 
that are characteristic of simple bruises of the extremities, when the 

l'h,. 38 




Erythema bullosum. (Howard Morrow.) 



injury has been sufficient to cause extravasation of blood. The lesions 
occur in various shapes, sizes, and shades, and the number of names 
used to designate their several appearances require explanation. 

The subjective symptoms are exceedingly mild and are quite out of 
proportion to the severity of the eruptive manifestations, slight burn- 
ing and smarting occasionally being present. 

The term erythema annulare (or circinahim) is employed to designate 
the lesions having a depressed centre and an erythematous margin, 
forming a ring. Occasionally, these rings are arranged concentrically. 
When several rings coalesce by peripheral extension, gyrate figures are 



ERYTHEMA MULTIFORME 



formed, and tins is termed erythema figuratum. Erythema marginatum 
describes a form in which a distinctly elevated and well-defined mar- 
ginal band is left as the sequel of an erythematous patch. Erythema 
papulatum (or papillosum) and erythema tuberculatum (or tuberculosum) 
are those tonus in which occur lesions respectively of a papular or 
tubercular type, pea- to bean-sized, flattened, discrete, or closely 
packed together, usually of a characteristic purplish color. Erythema 
urtieatum is characterized by severe itching, and presents in addition 
to the characteristic lesions of the disease those due to trauma from 



Fig. 39 




Erythema bullosum. (Howard Morrow.) 

scratching. Erythema vesiculosum and erythema bullosum are excep- 
tional forms, in which exudation is sufficient to produce lesions of this 
type rather than the edema which occurs in other types. These lesions 
may be situated at the centre or periphery of an erythematous patch, 
or occupy the centre of the papule or tubercle. The fluid is usually 
removed by absorption and is rarely set free by rupture of the vesicle 
or bulla. 

Erythema Iris { Herpes iris, Hydroa vSsiculeux) is the result of the 
evolution of successive erythematous circular lesions, which at times 
lorm several differently shaded concentric rings. The dorsum of the 



154 



HYPEREMIAS AND INFLAMMATIONS 



hand is the usual site of this efflorescence, though the face and mouth 
may be attacked. At the onset, there appear one or several vesicles or 
vesico-papules, which pursue their rapid career in two or three days. 
Upon the hyperemic ring which surrounds these lesions, a second and 
even a third or fourth circlet of similar lesions form, each pushing the 
areola further to the periphery of the patch. The older lesions are in 
full retrogression while the newer vesicles are in process of evolution; 
and the red blush which surrounds the earlier lesion is undergoing color 
changes from vivid to purple and paler hues while* the zone of the 
oldest vesicle IS assuming its Intensest shade. The lesions are pinhead- 
to pea-sized, rather persistent and firm, and terminate more often by 
resolution than bv rupture and crusting. The concentric and parti- 
colored rings may make up a single patch an inch or more in diameter, 
or several such patches ma} form upon the surface of the integument. 
In the hitter case, the central disk of some of the patches will be seen 
to he composed of confluent lesions. The subjective sensations are 
usually mild. 

1 1... hi 




Erythema multiforme. 



The term "multiform" given to this disease by Hebra is justified 
by the singular diversity of lesions which it displays. The lesions are 
remarkable not merely for their variety, but also for their occurrence 
in such variety both simultaneously and successively, and for the 
rapid change from one type to another. The erythema multiforme 
symptom complex may accompany such diseases as cholera, typhus, 
glanders, measles, gonorrhea, septicemia, and malaria. It is also seen 
comparatively frequently produced by the ingestion of many drugs, 
chief among which are quinin, arsenic, belladonna, chloral, salicylic 
acid, and iodin and bromin compounds. It follows also the injection of 
various serums, particularly the diphtheria antitoxin. A great variety 
of rashes occur following this, but the erythema multiforme complex 
occurs fairly often. Finally, there is a group of cases in which the 
general symptoms are of a marked character. General malaise, fever, 
inappetence, pharyngeal inflammation, chills, severe gastro-intestinal 
disorder, rheumatoid involvement of the articulations, and even 



ERYTHEMA MULTIFORME 155 

organic changes in the heart, lungs, ;in<l kidneys, have all been noted 

as coincident or causative phenomena. In many of these cases it i 

clear that t lie exant lieni belongs to the list of symptomatic er\ t Ik ma , 

and that it is of insignificance in comparison with the grave general 

condition. 

Corlett 1 describes a case of erythema circinatum bullosum ei hemor- 
rhagicum following a gunshot wound, apparently due to a streptococcic 
infection, and terminating fatally. The symptom complex in this 
case was that of multiform erythema. The etiology was a strepto- 
coccic infection, and, viewing the case from all standpoints, it appear- 
to have been one of those closely allied to certain forms of pemphigus, 
particularly the septic variety. Occasionally, mucous membrane* are 
affected to a disagreeable or even painful extent. Tims, a sudden 
tumefaction of the uvula may supervene upon the cutaneous symp- 
toms in cases sufficient to impede respiration; or the lining membrane 
of the larynx may be involved, and the resulting aphonia in varying 
degrees persist for two or three days. Hyperemic macules, vesicles, 
papules, and even blebs, may occur upon the upper and lower lips, 
inner fascia 1 of the cheeks, the gums, the soft and hard palate, and at 
times the pharynx. These lesions begin as pinpoint- to large-pea-sized, 
isolated, deeply tinted elevations. In severe cases, painful erosions 
form. The parts then become tender and swollen, and when hemor- 
rhagic erosions form there may be ulceration of a superficial character. 

Etiology. — The affection is commonest in the spring and autumn. 
It occurs in the young or in the early periods of adult life; the papular 
and tubercular forms more often in men, the nodose forms in women. 
Many patients are affected with rheumatism. Mackenzie 2 has called 
particular attention to this fact of the relationship of erythema 
multiforme to rheumatism and to purpura rheumatica. In three 
valuable contributions to the study of the visceral complications of 
erythema, Osier 5 has shown that the cutaneous symptoms may be 
merely surface expressions of a visceral disorder. In 29 cases studied 
by him, there were three sets of symptoms: (a) polymorphous skin 
lesions, including acute circumscribed edema, urticaria, purpura, and 
ordinary forms of erythema multiforme; (b) visceral lesions, including 
(1) gastro-intestinal crises, in which severe colic, with or without vomit- 
ing, diarrhea, or bloody stools, was frequent, (2) hematuria and nephritis, 
(.'$) hemorrhages from mucous surfaces, (4) cerebral symptoms, (5) 
pulmonary complications; and (c) infiltration of synovial sheaths 
and periarticular tissues and arthritis. In some of these cases a given 
visceral lesion has been accompanied at different times in the same 
individual by each of the types of cutaneous lesions. 

Pathology. Erythema multiforme is essentially a hyperemia of the 
integument, that under certain influence's advances more or less rapidly 
to the stage of a mild grade of inflammation, with consequent exnda- 

1 Jour. Cui. Dis., 1908, xxvi. p. 7. - Brit. .lour. Derm., 1896, viii, p. 116. 

Amer. Jour. Med. Sci., ISO."), ii. b., ex.. p. 629; Brit, .lour. Derm., 1900, \ii. p. l'l'7; 

and Vmcr. .lour. Med. Sci., 1<)01, exxvii, p. 1. 



156 HYPEREMIAS AND INFLAMMATIONS 

tion. Crocker, examining a patch of erythema tuberculatum, recog- 
nized merely a cell-effusion in the upper part of the corium extending 
sparsely below, and then chiefly along the ducts and follicles. There 
was slight rete-proliferation. The chief histological changes, according 
to Unna, are dilatation of the vessels, perivascular cell-infiltration, 
and edema of the collagen and elastin; the change's being chiefly noted 
in the papillary body. Secondary changes in the epidermis consist 
of edematous swelling of the epithelium, with moderate proliferation 
and a dilatation of lymph-spaces. In two cases of the moist type, 
Pardee 1 found simply an acute exudative inflammation of the upper 
part of the corium. Torok- and Kreibich 3 also find the condition to be 
a simple dermatitis and not an angioneurosis. 

Diagnosis. — The tendency of the disease to symmetrical arrange- 
ment upon the two sides of the body, the recurrence of lesions evi- 
dently dating from several periods in which successive crops appear, 
and the absence of all history of external injury will usually suffice to 
establish a diagnosis. Important points to be considered are the 
recognition of the vivid coloring of most of the lesions; their edematous 
character; their symmetry, as a rule; the pigmentation following those 
situated on the lower limbs; their frequent association with rheu- 
matism or rheumatoid pains, febrile phenomena, malaise, and other 
constitutional disturbances. From urticaria, it is distinguished by the 
type of the lesion; the wheals of the latter are smaller, more whitish 
centrally, more closely packed together, less symmetrical, rarely 
grouped, and, as a rule, more acute than those of multiform erythema. 
Cases difficult to assign to either disease are common, and an error in 
either direction is not serious. Certain rare forms are difficult to dis- 
tinguish from dermatitis herpetiformis. Whitfield 4 reports cases of 
multiform erythema of the papulo-pustular type which were mistaken 
for variola. We have seen two similar cases. Finally, certain rare 
forms are practically indistinguishable from pemphigus. 

Treatment. — As in the majority of instances the disease under con- 
sideration progresses naturally to a favorable termination within the 
course of a few weeks, the duty of the physician is usually limited to 
diagnosis, with a study of the etiology in each case, for the purpose 
of preventing future attacks. For the relief of the slight burning or 
itching present in some cases, a dusting-powder, sedative or antipruritic 
lotion, or protective dressings, such as are recommended for the treat- 
ment of acute eczema, may be employed. Bulla? and vesicles should 
be evacuated and protected with a simple aseptic dressing. Inter- 
nally, such medication should be employed as is indicated by the gen- 
eral condition of the patient. Iron, quinin, the salicylates, including 
aspirin, salol, strichnia, and dilute hydrochloric acid, will be found 
beneficial in many cases. Constipation and indigestion will be cor- 
rected by proper measures. A full dose of calomel or blue mass, 

1 Johns Hopkins Hosp. Bull., 1898, ix, p. 165. 

2 Archiv, 1900, liii, p. 243. 3 Ibid., 1901, lviii, p. 125. 
4 Brit. Jour. Derm., 1903, xv, p. 273. 



ERYTHEMA VODOSUM 



> i 



followed by a saline laxative, is demanded in many ca ea to aid in 
the elimination of intestinal toxins. When the disorder accompanies 
rheumatic or other systemic disease, internal treatment is to be directed 
to the general condition present. When the erythema produces 

extensive edema of the inula, incisions may be employed to prevent 
dyspnea and dysphagia. Recently, vaccines have been prepared from 
organisms obtained in the intestinal canal and employed with possibly 
some success. Gilchrist reports a favorable result in a case treated 
with a vaccine made from the Staphylococcus attms. This field 
promises results but requires further work. 

Prognosis. — It will be gathered from what lias been said that the 
prognosis is usually favorable, hut necessarily varies with the constitu- 
tional disease of which the ery- 
thema may he a mere symptom. Fig. 41 
The malady may relapse in sus- 
ceptible individuals at those pe- 
riods of the year when it is ob- 
served most frequently. Fatal 
cases, such as the ones quoted 
by Corlett and others, naturally 
make the prognosis in certain 
cases unfavorable. 

Erythema Nodosum (Derma- 
titis Contusiformis; Fr., Eryiheme 
noueux) is regarded by some 
authors as a distinct affection, 
and by others is classed as a form 
of erythema multiforme. Unna 
sees a distinction between this 
disease and erythema multiforme 
in the fact that the lesions of 
erythema nodosum never widen 
concentrically, never produce 
bullae, and never exhibit annular 
vesicles, although lesions of both 
types may occur in one patient. 
Erythema nodosum rarely if ever 
recurs, and, while there are many 
points of resemblance, it will be 
described here as a separate affec- 
tion. 

Symptoms. — The disease is usua 
tional disturbance, and is commonly associated with joint pains. 
The lesions occur chiefly on the legs below the knees, on the anterior 
surface. They are semiglohular, pea- to fist-sized nodules, pale-red, 
pinkish to livid blue in color, tender on pressure, and exhibit in their 
involution the variegated hue seen in a contusion. In addition, 
they may occur, though rarely, on the arms, trunk, and face. Though 




Erythema nodosum. (MacKee.) 
v ushered in with some constitu- 



158 HYPEREMIAS AND INFLAMMATIONS 

occasionally so soft to the touch that fluctuation seems to be present, 
they do not terminate by suppuration. At times, they appear to 
develop in crops. They are usually tender on pressure, and eft en 
painful. They may disappear in a fortnight, but occasionally remain 
for several weeks. The petechial appearance of the spots where they 
have existed is that of the characteristic black-and-blue mark. In 
rare instances the mucous membranes may be involved. 

Etiology. — Like multiform erythema, the disorder occurs most often 
in the spring or autumn, and most frequently in women, and is very 
commonly associated with rheumatoid pains. The eruption may 
occur in tuberculous subjects, 1 and it also occurs often in the poorly 
nourished and ill-housed. Xeara and Goodbjidge 2 recorded a case 
of erythema nodosum in a patient the subject of acute and fatal tuber- 
culosis. Other causes cited are malarial chills, temperature changes, 
endocarditis, urethral irritation (blenorrhagic, instrumental), the 
ingestion of drugs, alcoholic excesses, and dentition. Some stress has 
recently been laid on syphilis as an etiological factor. Joynt 3 reports 
erythema nodosum following measles in from ten to fourteen days in 
9 out of 300 cases. As cases not infrequently develop following a 
pharyngeal or tonsillar infection, it seems probable that the causative 
factor responsible -for the so-called rheumatic affections starting in this 
way is identical. 

Pathology. — Duhring 1 regards the' disease as in most instances infec- 
tious. Mackenzie believes true erythema nodosum to be a mani- 
festation of rheumatism, and in view of the modern conception of the 
infectious nature of many cases of rheumatism some light is obtained 
concerning the pathogenesis of the disorder. The histological study 
shows the ordinary signs of inflammation, including vascular dilata- 
tion, small, round-cell infiltration in the papillary and subpapillary 
layers of the corium, choking of the lymphatics and blood-vessels, and 
edema. Various micrococci and Demme's bacillus 5 have been dis- 
covered in the blood of patients suffering with erythema nodosum. 

Recently Rosenow 6 has isolated a microorganism from the sub- 
cutaneous nodes and blood of 6 patients suffering with erythema 
nodosum. He describes the organism as a polymorphous, sometimes 
clubbed, often curved, barred diplobacillus; and by injecting this 
organism intravenously in animals has produced subcutaneous lesions, 
exhibited as hemorrhages, followed by infiltration and migration of 
leukocytes, with enlargement of the regional lymph-glands. From 
these areas the organism has been repeatedly isolated. 

1 Morfan, La Presse medicale, June 26, 1909, p. 457: "Erythema Nodosum and 
Tuberculosis." Foerster, Trans. Amer. Med. Assoc., Sec. on Derm., 1914, p. 328: 
"The Association of Erythema Nodosum and Tuberculosis" 

2 Amer. Jour. Med. Sci., 1912, cxliii, p. 393. 

3 Brit. Med. Jour., April 15, 1911. 

4 Cutaneous Medicine, Part II, p. 276. 

5 Fortschr. der Med., 1888, vi, p. 241. 

6 "Etiology of Erythema Nodosum: Preliminary Note;" read before the 38th Annual 
Meeting of the Amer. Derm. Assoc, June, 1914. 



ERYTHEMA PERSTANS 159 

Diagnosis. The characteristic picture presented by erythema nodo- 
sum, with the bilateral localization of the lesions, usually present 
no difficulty in diagnosis. Syphilitic nodes and gummata are distin- 
guished by the absence of pain; the fewness of the lesions; their over- 
lying integument being untinted save when actually softening and 
approaching disintegration; their obvious subcutaneous site; their 
unilateral distribution; and the concomitant symptoms of late lues. 
Erythema induratum of Bazin is much more chronic, unattended by 
subjective sensations, and has a tendency to break down and ulcerate. 
It must also be remembered that potassium iodid and bromid produce 
lesions resembling this disorder, and in any case contusions and bruises 
should be ruled out. This latter question, at times, has a bearing in 
medico-legal questions, especially in the case of young children. 

Treatment. — As a rule, rest in bed is essential. This, with a light 
diet and free elimination, and the administration of sodium salicylate 
or aspirin, is all that is required. It is well to combine the sodium 
salicylate with bicarbonate of sodium, giving 0.33 of the former and 
0.()G of the latter four times daily. A mercurial purge, followed by a 
saline cathartic, to begin with, is of value. Locally, the application 
of heat will relieve the tenderness, and bandaging promotes absorption. 

Prognosis. — As a rule, in from two to six weeks the disease has run 
its course and clears up. Some patients have much temperature and 
suffer with sufficient pain to cause them great discomfort; but even in 
these cases the prognosis is good within the above-mentioned time limit. 

Erythema Perstans. — Several disorders have been described under 
the above title. Some of them were probably examples of multiform 
erythema of unusual duration. Under the title of Erythema perstans 
faciei, Kreibich 1 describes a toxic erythema developing on a lupus 
erythematosus as a sequel of influenza-pneumonia. This type is de- 
scribed in this work under the title Erysipelas perstans faciei ( Kaposi). 
Wende 2 describes a group of cases under the title Erythema figurata 
perstans. The same author 3 reported two cases under the title Ery- 
thema perstans presenting circinate lesions. These cases are described 
by AYende as follows: The disease begins with isolated papules, which 
spread peripherally and fade in the centre, forming circinate lesions. 
The outer half of the advancing margin is described as being smooth 
and slightly raised, while its inner edge presents sealing. Some pig- 
mentation follows. The lesions vary in size from that of a silver 
twenty-five-cent piece to that of the palm of the hand. The configura- 
tion also is variable, gyrate forms being common, due to confluence 
of circinate or annular lesions. Subjective sensations are sometimes 
rioted. Great variation occurs in the length of time required for the 
development of the lesions. Exacerbations also are variable as to 
time, the rule being that some lesions remain all of the time. The 
disease may occur at any age. 

1 Zeitschrift, 190S, Bd. 15, Heft. 8. p. 522. 

- Trans. Ahum-. Mod. Assoc, Sec. Cut. Med., 1908, p. 75. 
:! .Jour. Cut. Dis., 1906, xxiv, p. 241. 



1G0 HYPEREMIAS AND INFLAMMATIONS 

Etiology. — "While the etiology is unknown, it is suggested that a 
toxemia originating in the alimentary tract is probably responsible. 
The microscopic changes described show a superficial inflammatory 
process, with dilatation of blood-vessels, edema, and perivascular 
cell-infiltration, consisting of round, plasma, and connective-tissue cells. 
Secondary changes in the epidermis are shown to be edema and para- 
keratosis. 

Treatment. — Treatment has only been of value temporarily. Chrys- 
arobin and .r-rays both have been used, the former with better results. 
Internally, medication was valueless. 

Erythema Infectiosum. The disease bearing this title appears 
to be an acute exanthematous disorder somewhat resembling rotheln. 
Apparently it was firsl recognized by Escherich. 1 Other reporters 
arc Ileimann- and Shaw. 3 The disease is epidemic and occurs 
in children, commonly between the ages of four and twelve years. 
The Incubation period is from six to fourteen days. The erup- 
tion, as a rule, begins on the face, spreading dike erysipelas, having 
sharply defined outlines. There is intense redness and turgescence 
of the cheeks. On the extremities, bluish-red, erythematous patches 
occur. Iii some cases, in these regions the eruption resembles rotheln. 
It lasts, as a rule, from six to eight days and then gradually fades, first 
on the face and later on other areas. It is not followed by desquama- 
tion or sequela;. 

Erytheme Miliaire Leucogenique Prurigineux Chronique. — Milian 4 
under this title described an eruption occurring in a patient who had 
suffered with urticaria for >ix years. The present eruption, which was 
of six weeks' duration, was situated on the trunk, especially about the 
flanks, also on the thighs and extremities. The lesions were pinhead- 
sized, slightly elevated, red spots, surrounded by a whitish zone, and 
were the seat of intense itching. The appearance of the eruption 
suggested an unusual form of urticaria pigmentosa. 

Erythema Elevatum Diutinum. — Under this title, proposed by 
Campbell Williams and Crocker, 5 is described a rare disease char- 
acterized in most instances by the appearance of pea- to bean-sized, 
firm, painless nodules, which are pink at first but gradually assume a 
purplish hue. At first distinct, the nodules tend to coalesce to form 
irregular-lobed infiltrations; flat, raised plaques or, in exceptional 
cases, distinct nodular tumors. The lesions have been encountered 
chiefly on the extensor surfaces of the limbs and joints, but have also 
been seen on the palms and soles, buttocks, and ears. In most of the 
cases reported, the lesions persisted for years, though in two cases they 
gradually underwent involution. The patients have been children 
or young adults, and usuallv females. They showed either a personal 
or family tendency to gout or rheumatism. 

1 Munch. Med. Wochnschr., 1904, xxiv. 

2 Arch. f. Kinderh., Berlin, 1904, lx, p. 421. 

3 Amer. Jour, of the Med. Sci., January, 1905, p. 16. 

4 Annales, 1906, vii, p. 48; Jour. Cut. Dis., 1907, xxv, p. 12S. 

5 Brit. Jour. Derm., 1894, pp. 1-9 and 33-38. 



OR I \ ULOMA .1 \ \ UL iRE 161 

Stelwagon 1 records four cases of similar nature occurring in adult-, 
all past forty years of age, the lesions being situated on the face, l - 
and cheeks. 

Ilartzell- believes erythema elevatum diutinum is simply a clinical 
variety of granuloma annulare. 

Pathology. -Williams and Crocker describe a fibro-cellular process 
of Inflammatory origin, situated deeply in the corium. The sweat- 
glands apparently were little if at all involved. 

Treatment proved unsatisfactory. 

GRANULOMA ANNULARE. 

Synonyms. — Ringed Eruption (Colcott Fox), Eruption chronique 
circinee de la Main (Dubreuilh), Lichen Annularis (Galloway), Granu- 
loma Annulare (Crocker), Sarcoid Tumors (Rasch), Xeoplasie circinee 
et nodulaire (Brocq), Erythemato-Sclerose circinee du dos des Mains 
(Audry), Tumores Benigni Sarcoidei Cutis (Galewski), Stereophlo- 
gose nodulaire and circinee (Pellier). 3 

Definition. — A comparatively rare disease characterized by papules 
or nodules grouped in a ringed or circinate arrangement, pursuing 
a chronic course, and devoid of subjective symptoms. 

The disease has been studied by E. Graham Little 4 in addition to 
the above reporters, and much of the description found here is taken 
from his excellent resume. 

Symptoms. — The primary lesion is a deeply seated nodule or a ring of 
closely grouped nodules of firm consistency, elevated, sharply circum- 
scribed; whitish, pinkish, reddish, purplish or bluish-red in color. The 
rings are oval or round, and vary in size from half an inch to two or more 
inches in diameter. The border is elevated from one-sixteenth to one- 
eighth of an inch, being usually elevated one-sixteenth of an inch. The 
lesions may be surrounded by a reddish areola, and the centre may be 
normal, reddened, or even atrophic or cicatricial. The ring may 
undergo involution irregularly, having crescentic and festooned figures. 
There may be but a single lesion or a large number, twenty or more 
having been noted. The lesions may develop suddenly or slowly, and 
may persist for months or years. There is little tendency to spon- 
taneous involution, although this may at times occur. No sequels 
are left except in the cicatricial cases. The disease is seen most fre- 
quently on the dorsum of the fingers, about the wrists, elbows, neck, 
feet, ankles, and buttocks. In the three cases studied by ourselves 
(one histologically), lesions occurred on the fingers, below the knee, 
and on the ankle. The age of the patients has varied from eighteen 
months to fifty-two years. Ilaldin Davis 5 reports the case of a patient 

1 Dis. of the Skin, 7th Ed., p. 169. 

'-' Trans. Amer. Med. Assoc, Sec. on Derm., L914, i, p. 27: "Granuloma Annulare." 
1 Annales, January, 1910, p. 2S; abstr. Brit. Jour, of Derm., 1911, xxiii, p. 32. 
1 Brit. Jour, of Derm., L908, xx, pp. 213 248 and 281 317. A critical study of 19 
cases, 6 personal. Full bibliography to this date. 
■• Brit. Jour, of Derm., L910, xxii, p. 90. 
11 



162 HYPEREMIAS AND INFLAMMATIONS 

sixteen months of age. The major portion of cases occur in children 
and young adults. 

Etiology. — The cause of the disease is obscure. Crocker found 
evidence of tuberculosis in some of his cases, and Little 1 found marked 
tubercular antecedence in several cases, and was inclined to view 
tuberculosis as an etiological factor. 

Pathology. In Little's collective study, the histology is summar- 
ized as follows: In the deeper curium and hypoderm, groups of cells 
constituting a microscopic nodule were noted about coil-glands, hair- 
follicles, and blood-vessels. Areas of degeneration were occasionally 
noted in these cell-masses. In addition, there were rows of cells extend- 
ing upward along the tracts of coil-ducts and hair-follicles, also some 
horizontal rows of cells, a> well as a scattered cellular infiltration in the 
corium. The type of cell is given as large mononuclear, spindle, pear- 
shaped, and oblong connect ive-tissuc cells, and the so-called epithe- 
leoid cell. The epidermal changes were insignificant; some thickening 
of the pete and stratum corneum was noted in certain cases, and in 
some the normal waxy line between the epidermis and corium was 
obliterated oxer a nodule. In the case we studied histologically, the 
changes were those usually seen in keloid. 

Treatment. Dsually simple local treatment is sufficient. Salicylic- 
acid plaster, ichthyol or rcsorcin has been found efficient. Jadassohn 
used arsenic internally. 

Prognosis. Untreated, the lesions persist and tend to spread and 
last Indefinitely, but with simple treatment readily disappear. The 
disease may recur. 



PURPURA ANNULARIS TELANGIECTODES. 2 

Synonym. — Telangiectasia Follicularis Annulata (Majocchi). 

This rare disease was first described by Majocchi in 1890. About 
thirty cases have been recorded in Italy, France, and Germany. 
The first case studied in America was recorded by MacKee. 3 

Definition. — The disease is characterized by telangiectatic, purpuric, 
and atrophic lesions, usually occurring on the lower extremities. The 
symptom complex appears sufficiently characteristic to warrant its 
recognition as an entity. 

1 Loc. cit. 

2 Majocchi, Archiv, 1898, xliii, p. 447 (report of three cases not hitherto described, 
with histological study); Brandweiner, Monatshefte, 1906, xliii, p. 529 (three cases 
reported, with histological study in one); Rodoeli, Giorn. ital., 1911, ii (abstr. Archiv, 
1911, ex, p. 320); Lipschiitz, Archiv, 1912, cxii, p. 1017; Brandweiner, Derm. Woch- 
enschr., 1912, lv, p. 1292 (two additional cases reported, with bibliography); Vignolo- 
Lutati, Archiv, 1912, cxiv, p. 303 (case report, with histological study); Lindenheim, 
Archiv, 1913, cxiii, p. 689 (case report, with histological study); Pasini, Giorn. ital., 
March, 1913 (abstr. Archiv, 1913, cxv, p. 1051; a clinical and histological study). 

3 "Purpura Annularis Telangiectodes;" paper read before the Amer. Derm. Assoc, 
at its thirty-eighth annual meeting, May, 1914, Chicago (a clinical and histological 
study, with a description of the disease as recorded in the literature. To this article 
the author is much indebted). 



PURPUR i i \ \ ULARIS TEL I VGIECTODES 



163 



Symptoms. According to MacKee's rSsumS of the recorded ca e . 
the symptoms of the disease may be divided into three fairly well- 
defined stages, as follows: telangiectatic, purpuric and pigmentary, 
and atrophic. The early lesions arc minute red puncta. These slowly 
increase in size by peripheral extension, producing lesions from split- 
pea- to dime-sized and larger. The color may be removed from the 
early lesions by pressure, but later, in the purpuric stage, the color is 
permanent. As the lesions spread peripherally, they clear in the 
centre, producing in some cases slight atrophy. After several months, 
the lesions disappear, leaving pigmentation. While the eruption is 
usually situated below the knees, on the anterior and lateral surfaces 



Ftg. 42 




Purpura annularis telangiectodes, showing annular lesions. Some of the margins depict 
purpuric spots and others show necrosis. (MacKee.) 



of the limb, at certain times lesions may be found above the knees, on 
the arms, and rarely in other situations. In occasional instances, the 
eruption is preceded by some constitutional disturbance, indicated by 
neuralgia or rheumatic pains. 

According to Majocchi, it should have the following characteristics: 

(1) rose-colored or livid spots formed from capillary dilatation, fol- 
lowed by hemorrhage, without previous hyperemia or any infiltration 
of the skin, and usually in distinct connection with the hair-follicle; 

(2) slow development and increase in size; (3) constant eccentric 
growth of the spots, resulting in definite ring forms; (I) symmetrical 
arrangement; (5) the primary location always on the extremities. 



1G4 HYPEREMIAS AND INFLAMMATIONS 

usually the lower; (0) the usual absence of subjective symptoms; and 
(7) commonly leading to slight atrophy and achromia of the skin, to- 
gether with alopecia. Instead of rings, the lesions may form half- 
circles, as described by Lipschiitz. The course of the disease is slow, 
but with a tendency to clear up after several months. Brandweiner 
states that the lesions disappear spontaneously after a few months' 
duration without scar-formation, and according to this author's obser- 
vations new lesions not infrequently occur through trauma induced by 
scratching. 

Etiology. The disease usually attacks young male adults. 
Majocchi states that the etiology is obscure 1 , but that the disease is 
probably a vasomotor phenomenon, having some resemblance to ery- 
thema pernio. Most authors believe the disease to be either of toxic 
origin or a neurosis. While usually occurring in adults, it has been 
seen in children. 

Pathology. Histologically, the capillaries are found to be dilated, 
and there occurs a perivascular cellular infiltration. In certain cases 
diapedesis of red-blood corpuscles occurs, and hemorrhagic areas are 
noted, with deposits of pigment. The lymph-spaces are also dilated, 
and there appears to be an increase in the number of small capillaries. 
Phlebitis and obliterating endarteritis are noted. In the final stage, 
the epidermis becomes atrophic and the papillae are obliterated. Rodoeli 
suggested a connection between the disease and tuberculosis. Some 
cases have given a positive tuberculin reaction, but inoculation experi- 
ments have been uegative. Most authors agree that there is no con- 
nection between the two diseases. MacKee found in an early lesion 
endarteritis, with increase in the number of small capillaries, edema 
in the coriinn, and hyalin degeneration of the arterial walls. In some 
places aneurysmal sacculation was noted. Hemorrhagic areas also 
occurred, and in addition a moderate amount of perivascular cellular 
infiltration, the cells being small lymphocytes. In a chronic lesion 
the epidermis was atrophic; the corium was edematous and contained 
a few vessels; there was endarteritis, with partial obliteration of the 
lumina ; and hemorrhagic and pigmented areas occurred throughout 
the corium, with some perivascular cellular infiltration. The append- 
ages were normal. 

Diagnosis. — The disease is to be distinguished from syphilis and 
from ordinary purpura, but by noting the classical symptoms as de- 
scribed above little difficulty should be experienced. 

Treatment. — As the cases tend to clear up of themselves, little 
treatment is necessary. Rest in bed, with elevation of the limbs, is 
recommended. In case this cannot be carried out, suitable bandaging 
would be of value. In rare instances, where necrosis occurs, as in 
MacKee's case, these areas should be treated with mild antiseptic 
lotions or ointments. 

Prognosis. — As indicated above, the prognosis is good, always 
remembering the possibility of recurrence. 



URTICARIA 165 

A PECULIAR PROGRESSIVE PIGMENTARY DISEASE OF THE SKIN. 

Synonym. Schamberg's Disease. 

An affection was described under the above title by Schamberg 1 
in 1900. A number of similar cases have since been recorded. 
The disorder progresses slowly and occurs in the form of irregular 
patches. In Schamberg's first case the patches are described as 
follows: They are sharply defined, of a reddish-brown color, vary in 
size, and at the border are visible a number of small outlying macules 
of the same color and of the size of pins' heads. The borders of other 
patches are made up of pinpoint- to pinhead-sized, reddish pnncta, 
closely resembling grains of cayenne pepper, though darker in tint. 
Some present a somewhat telangiectatic appearance. As the lesions 
undergo involution, a slight, diffuse, brownish-yellow staining is left. 
There are no subjective sensations. 

The disorder began over the shins and spread over the ankles and 
dorsum of the feet. There were also lesions about the knees and on 
the flexor aspects of the wrists. 

The disease apparently begins as pinhead-sized, reddish puncta or 
dots, forming irregular patches, which slowly extend by the formation 
of new lesions upon the periphery. The puncta in time disappear, 
leaving behind a brownish, brownish-yellow, or reddish-brown pig- 
mentation, which slowly fades (Schamberg). 

A histological examination reveals a subacute inflammatory process. 
The most marked changes are noted in the papillary and subpapillary 
layers, where there occurs a dense cellular infiltration, composed of 
lymphoid cells and polymorphonuclear leukocytes, with a few epi- 
thelioid cells. In addition, there are stellate, fusiform connective- 
tissue cells and a few mast-cells. Dilated blood-vessels and lymph- 
spaces are present. Pigment-cells and granules are absent. Infiltra- 
tion occurs particularly about the sweat-ducts, in some places sufficient 
to produce obstruction. 

The disease is to be differentiated from purpura and angioma serpig- 
inosum. 

URTICARIA. 

Synonyms. — Hives, Nettle-rash. Fi\, Ortie; Ger., Nesselsucht, 
Nesselausschlag. 

Definition. Urticaria is an acute or chronic disorder of the skin 
characterized by the presence of wheals, which are, as a rule, spherical 
and of a white or reddened color, and which induce varying degrees of 
itching, tingling, and smarting sensations. 

Symptoms. — The disorder may be ushered in by constitutional 
symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
phenomena, lasting for a few hours or even a day or more. 

With or without such prodromic symptoms, the eruption suddenly 

1 Trans. Amer. Derm. Assoc, L900; and idem, Brit. Jour. Derm., \w\, xiii. p. 1. 



166 



HYPEREMIAS AND INFLAMMATIONS 



appears in the form of wheals which frequently disappear with 
equal rapidity, leaving no trace of their existence save a slight and 

transitory hyperemia of the affected spot. The lesions usually are 



anon 



t the size of a finger-nail or a coffee-bean ; hut occasion 



illv 



they may cover a surface equal to that of the palm of the hand 
or much larger. Flat elevations occasionally occur, which may 
cover a large part of the trunk and limbs. In color the lesions are 
rosy-red or whitish, and are usually surrounded by a h\ perenhc areola. 
They may be isolated and few, or be numerous and closely packed 
together; they ma\ even coalesce, so that the individual wheals are 
scarcely recognizable. They are usually firm or semisolid to the touch. 
In contour they are roundish or oval-shaped, but a variety of curious 



Fi< 



Mi 




Dermographism. 



outlines may result from the irregularity of their development. Con- 
centric circles, lines, points, bands, and even figures, are in this way 
produced. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus, urticaria annularis occurs in rings; urticaria figurata in gyrations, 
from the union of several lesions or patches of lesions; urticaria vesic- 
ulosa and urticaria bullosa, where there is a vesicular or bullous develop- 
ment at the summit of the lesion; urticaria papulosa (described in this 
text under the title lichen urticatus) ; urticaria tuberosa, where "giant" 
wheals occur, some attaining the size of a hen's egg; urticaria hemor- 
rhagica (purpura urticata), where the urticarial element is developed 



URTICARIA 167 

in 8 lesion produced by cutaneous hemorrhage (Beck 1 recorded a case 
in which hemorrhagic lesions followed ;i tonsillectomy in a patienl 
suffering with ordinary urticaria); urticaria evanida and urticaria per- 
stans, where there is, respectively, a rapid or a slow process of involu- 
tion in the characteristic symptoms; and urticaria solitaria, where 
there is a single recurring lesion. 2 

Urticaria Factitia is a term employed to denote a form where the 
irritability of the skin is of such a degree that wheals may he induced 
by local irritation. The finger-nail drawn across the unaffected por- 
tions of the skin will produce a linear wheal ("urticarial autogram") of 
extent corresponding with the line of irritation (dermographism). The 
lesions thus produced may he transitory or last for some time. Occa- 
sionally, this condition exists in patients not the subject of the ordinary 
wheals. 

The subjective sensations in urticaria are distressing in varying 
degrees according to the susceptibility of the individual. Every grade 
of itching, burning, tickling, crawling, pricking, and especially sting- 
ing, sensations is thus engendered. The efforts of the patient to secure 
relief by scratching not only serve further to develop the eruptions, 
but also to irritate, tear, and otherwise wound the lesions already in 
full evolution. In this way lesions ordinarily transitory in their course 
may be changed to more persistent, deeply colored, flat, lenticular 
papules. Where the skin is delicate and thin, as is that of the lids and 
prepuce, considerable edema may result. 

All parts of the body may become affected. The mucous membranes 
of the mouth, pharynx, and larynx may occasionally become involved. 

The rapidity of the appearance and disappearance of the lesions 
visible upon the skin is a characteristic feature of the disorder. In 
some instances, only a few moments are required after the operation 
of an efficient cause to develop a large number of closely packed wheals. 
Even while they are under inspection, it can be noted that there is a 
change in individual lesions, some fading or completely disappearing 
while others are newly developing. 

The course of the disease varies, being, as a rule, acute, the recurring 
lesions tending to disappear within a few r days. In other cases the 
disease may become chronic and last for years by the constant develop- 
ment of new lesions. In many cases apparently trivial the disease 
may become so aggravated that its relief taxes the skill of the physician 
to a high degree. 

Urticaria, like erythema, may be either idiopathic or symptomatic; 
and in each form the urticarial conditions may underlie or be super- 
imposed upon almost every elementary lesion noted in the integument. 
The wheal may complicate, or may be complicated by, the macule, 
papule, tubercle, vesicle, bulla, or pustule. It is common in trauma- 

1 Monatshefte, L908, bcvii, p. 393 ; abstr. Jour. Cut. Dis., L909, xxvii, p. II. 

*Vorner, Zeitschrift, 1913, xx, p. 1; abstr. .lour. Cut. Dis., L913, \\\i. i>. 796 
(reporl of a case <>l urticaria characterized by one lesion recurring in the same locality, 
thus resembling herpes). 



168 HYPEREMIAS AND INFLAMMATIONS 

tisms, and is a prominent symptom in the skin bitten by insects, rep- 
tiles, or domestic animals. Baker 1 reported a case of urticaria tuberosa 
characterized by the presence in various parts of the body of persistent, 
yellowish-red tubercles, that proceeded to ulceration. The parts 
most affected were the knuckles, the elbows, and the ears. These 
tubercles were said to have begun in the manner which characterizes 
the onset of evanescent urticarial wheals and tubercles. A somewhat 
similar case was observed by McCall Anderson. 2 

I nder the title urticaria tuberosa verrucosa, a number of cases of 
anomalous urticaria have been recorded (Cf. chapter on Prurigo 
Nodularis). 

In occasional instances, the urticarial lesions may be followed by 
pigmentation, which bears a slight resemblance to the lesions of 
urticaria pigmentosa. These cases are usually chronic. Other cases, 
termed urticaria recidiva, occur in which new lesions of the usual type 
are constantly appearing during a period of from several months to 
many years. Several chronic types of urticaria have been described 
under such titles as urticaria perstans (iuberosis cutis pru riginasa)* and 
acne urtica, 4 varieties of urticaria in which pigmentations, nodules, 
and verrucous- and lichen-planus-like lesions dominate the clinical 
picture. 

Urticaria in Infants and Children (Lichen Urticatus). — Under this 
title Colcott Fox 8 described what he considered the urticaria of child- 
hood. It differed in many respects from that seen in the adult, and he 
and many others state that the usual urticarial wheals seen in the 
adult cases are not common in childhood. At a later period the same 
author' 1 describes this disorder under the title lichen urticatus, a disorder 
originally described by Bateman. 

The distinguishing features of this variety of urticaria are the fol- 
lowing: It is persistent, lasting for many years, having exacerbations, 
periods of quiescence, and relapses. It is usually worse in the summer 
season, and is characterized chiefly by papules. These are the pre- 
dominant lesions seen when the patient is examined, and are found on 
any part of the body, but are most numerous on the trunk. They are 
prurigo-like, pale or reddish in color, and irregularly disseminated. 
They are preceded at night, according to Fox's observation, by the 
occurrence of a wheal or wheal-like area, which excites the greatest 
distress in the infant during that time. In the centre of this area the 
papule forms. Occasionally, in places papules, vesicles, vesico-pustules 
or pustules occur. In certain cases,, on the hands, large vesicles and 
bullae appear, strongly resembling scabies. In addition, at times, 
secondary infections are present, together with all the symptoms of 
a marked traumatic dermatitis. 

1 Lancet, August, 1881, i, p. 153. 

2 Brit. Med. Jour., 1883, i, p. 1103. 

3 Archiv, lxxxi, p. 208. 

4 Ikonographia Dermatolodca, Fasc. i, Tab. ii. 

5 Brit. Jour. Derm., 1890, ii, pp. 133 and 176. 

6 AUbutt and Rolleston's System of Medicine, vol. ix, p. 238. 



URTICAR1 I 169 

These cases are to be differentiated chiefly from scabies and prurigo. 
After careful observation through ;i period of several years, Fox eon- 
eludes that lichen urticatus and prurigo are differenl disorder 

Etiology. Idiopathic urticaria results from the action of external 
irritants, prominent among which are the bites or stings of mosquitoes, 
lice, fleas, bed-bugs, gnats, wasps, bees, and caterpillars. The wounds 
inflicted by the jelly-fish give rise to a stinging or burning sensation, 
which induces the patient to rub or scratch the part. A wheal is 
rapidly formed at the site of the injury, and the irritation set up is 
conveyed to other parts of the skin in the vicinity; so that a single 
traumatism may excite an urticaria covering a much larger area. This 
is true of the bites of the various insects above mentioned. Many 
vegetable substances have an irritant action upon the skin. The nettle 
(Urtica urens and U. dioica) exhibits this characteristic to a high 
degree and has given the malady its name. A large number of other 
agencies operating externally may produce an urticaria in individuals 
predisposed to the disease or having a peculiar intolerance for a par- 
ticular substance. Climatic influences, more particularly those in 
which the surface of the body is exposed to cold air, are efficient in the 
production of urticaria, as also of bronchial asthma, with the symp- 
toms of which the disease under consideration, in the case of adults, 
may often coexist or alternate. Mechanical violence, the application 
of leeches to the skin, and surgical traumatisms may also act as 
exciting causes. 

Symptomatic urticaria is chiefly of the variety named by authors 
ah ingestis, since it most frequently results from medicinal or dietary 
articles taken into the stomach. 

Among the medicinal articles capable of producing urticaria may 
be named the balsams, the turpentines, quinin, glycerin, chloral, 
valerian, arsenic, hyoscyamus, cinchonidin, salicylic acid and the 
salicylates, senna, santonin, opium and its alkaloids, and the various 
vaccines, including the antitoxins, the last-named producing both 
ordinary urticaria and urticarial erythema in a large number of patients 
thus treated, and in some cases of a severe grade. 

Among the dietary articles capable of producing urticaria may be 
named eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery, 
lobsters, clams, caviar and several species of fish-roe and fish generally, 
grapes and their skins, nuts, dates, raisins, figs, prunes, strawberries, 
gooseberries, raspberries; canned (tinned) fruits, meats and vegetables; 
oatmeal, cucumbers, peas, beans, onions, garlic, corn, mushrooms, 
pickles, sauces, honey, pastry, salads, and spinach. Vinegar, cham- 
pagne, beer, and alcoholic beverages in general are capable of producing 
a similar effect. 

In children and infants a severe urticarial efflorescence may be 
invoked reflexly by worms, or by any undigested food, or indigestible 
material of any sort that may have passed into the stomach. In 
adults, also, who have experienced repeated attacks of urticaria, 
and suffer from sensitiveness of the eastro-intestinal tract, any food 



170 HYPEREMIAS AND INFLAMMATIONS 

not easily digested by a given individual may induce in him a return 
of the disagreeable symptoms. 

This undue sensitiveness to the effect of ingesta or of external irri- 
tants is often an idiosyncrasy peculiar to the individual either on spe- 
cial occasions or at all times; and, given this susceptibility, the effect 
is often great with a relatively insignificant etiological factor. Thus, 
a small quantity of beer, one grain of quinin, a small fragment of 
cheese, or hut a single strawherry may not only induce an urticarial 
rash of such an extent as to cover the greater part of the surface of the 
body, hut will also do the same on every occasion when the articles 
named are swallowed in the quantities given. It is important, there- 
fore, to recognize the fact that the smallest amount of an ingested 
substance may he responsible for severe symptoms, the important 
factor being individual susceptibility. In exceptional cases, the mere 
odors of iodoform, linseed, liquorice, or certain plants have been suf- 
ficient to cause an attack of urticaria. 

Other causes of urticaria may he cited, such as moral emotions- fear, 
shame, anger ( k'reibich and Sohotha, 1 recording a case of this type, 
discussed the question of psychic urticaria) and diseases of the re- 
spiratory organs, especially asthma ; gastro-intestinal disorders in which 
ingesta play no part; intestinal parasites; malaria; disorders of the 
uterus, the kidneys, and the nervous centres; dentition, pregnancy, 
and irregularities attending the menopause; and, lastly, those following 
special diseases, such a- pemphigus, prurigo, rheumatism, purpura, 
and variola. 

Pathology. -Urticaria usually is classed as a vasomotor neurosis. 
The wheal is a sharply circumscribed edema, and is developed appar- 
ently by an interchange of play between the blood-vessels, muscles, 
nerves, and tissue. There is, first, under the influence of the vaso- 
motor nerves, a clonic spasm of the arterioles in a limited area of the 
derma, by which is produced an acute edema with serous exudate. 
The rapidity with which this clonus occurs is greater than that with 
which the tissues of the vicinage can accommodate themselves to it, 
either by imbibition or more diffuse tumefaction; and there results a 
counter-pressure upon the affected capillaries, by which their lumen 
is still further restricted. As the wheal is not a purely fluid-containing 
nor yet an entirely solid lesion, but is semifluid in consistency, the 
mechanical pressure is greater at its centre and less at its periphery. 
Thus are explained the white and relatively bloodless appearance of 
the centre of certain wheals and their rosy or reddened outer border. 
The explanation is strengthened by the fact that generally the most 
acute lesions, those springing into view most rapidly, are chiefly char- 
acterized by this whitened centre; while those more indolent or even 
chronic in their career have a light-crimson, or even at times a dull-red, 
centre. Wheals have been excised and microscopical examination 
made by Neumann, Vidal, Poncet, Unna, and others, with the result 

1 Archiv, xcvii, p. 187. 



URTIC Ml i 171 

of discovering merely evidence of dilatation and engorgemenl of the 
blood- and lymph-vessels. The deeper lymph-channels show the 
greater engorgement and this, by compression of the more superficial 
blood capillaries, induces the whiteness of the acutely developed \\ heal. 
Inn;! believes that the wheal is produced by a spastic contraction 
of the vein. That the lesion may he inflammatory rather than the 
result of an angioneurotic process seems to have been proved by 
several observers. 

Gilchrist 1 found fragmentation of nuclei in a section of factitious 
urticaria excised three minutes after production, which seemed to 
show death of cells preceding the inflammatory changes. Sections 
of wheals from severe cases showed marked immigration of poly- 
morphonuclear leukocytes, emigration of lymphocytes, pronounced 
fragmentation of polymorphonuclear leukocytes and fixed connective- 
tissue cells, apparent increase in mast-cells, swelling of the cells 
of the sweat-glands, and fibrin scattered throughout the corium. 
From this picture, which is typical of acute inflammation, he concludes 
that there is some toxin circulating in the blood, and when a wheal 
is produced some of the toxin is set free, which causes death of the 
ceils and is followed by acute inflammatory changes. Torok 2 also 
finds not infrequently evidence of simple inflammation. Torok and 
Hari, 3 and Philippson, 4 as the result of numerous experiments, conclude 
that urticaria, also the edema which is present, is due to the direct 
action of an irritant upon the vessels at the point where the cuta- 
neous lesions are produced, and that the disorder is not therefore 
an angioneurosis. The toxins may reach the vessels from within or 
from without. 

Diagnosis. — The diagnosis of classical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which confu- 
sion may arise. The chief points to be remembered are: the rapidity 
of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action of the animal parasites 
and of insects not parasitic should not be overlooked, and the rash 
should be closely examined for the minute wounds inflicted in this 
way, often covered with a pinpoint- to pinhead-sized, dried "blood- 
scale," and usually found in groups of two, three, or more lesions. 
The various forms of erythema papulatum, tuberculatum, and nodosum 
may be mistaken for urticaria; but this is in many cases inevitable, 
as intermediate forms between the two disorders are with. difficulty 
assigned to either category. Absence of marked subjective sensations 
and persistence of lesions generally point to an erythema, while marked 
prevalence of these symptoms would decide in favor of urticarial dis- 
ease 1 . 

In many cases the 1 physician is consulted by a patient who gives a 

' Trans. \ I [nternat. Derm. Congress, New York, L907, ii, i>. 905. 
' Aichiv, 1<)()<), liii, p. 243. 
[bid., L903, Ixv, i». 21. ' Ibid., p. 387. 



172 HYPEREMIAS AND INFLAMMATIONS 

history of well-nigh intolerable distress at night or at other odd times, 
and who repeatedly and vainly endeavors to exhibit the lesions as 
they appear upon the skin. Being examined on various occasions, 
scarcely a trace of cutaneous disorder is manifest. Here the prac- 
titioner has actually to decide upon the character of an eruption he 
never sees. The task i> rarely difficult, no other than the urticarial 
eruptioD beginning in this fashion. Occasionally, delicate rosy or 
deeper stained mottlings of the skin-surface remain where the wheals 
have been. At times, also, on the flexor aspect of the forearm, or in 
some situation in which the skin is equally delicate, one or more typical 
lesions may be produced by the aid of a finger-nail in scratching, or by 
rubbing. These cases are frequently of the chronic, or at least of the 
relapsing, class, and the victims of the disease may have a characteristic 
facies, ;i worn look from h»s of sleep or from emotional disturbance. 

The several lesions of erythema are larger than those of urticaria, 
and they do not develop from characteristic wheals; in erythema multi- 
forme the lesions are far more persistent in type and do not provoke 
the characteristic subjective sensations of urticaria; in erysipelas the 
redness is characteristic and the swelling more diffuse. 

Treatment. Naturally, the firsl indication to be observed is the re- 
moval of the cause, and with this, if possible, accomplished, the next is 
the exclusion of all aggravating agencies. The discovery of the cause, 
at times readily effected, is often the most serious problem presented. 
An exhaustive and minute examination of the person and the history 
of the patient, a study of his food, drink, medicine, regime, clothing, 
sleeping apartment, habits, occupations of life, and mental state, are 
here essential. When the disorder is recent, and is an urticaria ab 
ingestis, a brisk emetic or a eathartie may rid the stomach or the 
bowels <»f offending matter-. A- a rule, a light diet should be outlined 
for the following several days. In many cases the alkalies are of value, 
and often the preparations of sodium, potassium, or magnesium are 
employed. Laxatives, such as rhubarb, magnesia, the cathartic min- 
eral waters, and, in ease of children, small doses of castor-oil, are fre- 
quently indicated, even when there is no suspicion of irritating ingesta. 
At other times there is marked atony of the digestive organs, and in 
such cases the mineral acids, the bitters, and the ferruginous tonics 
may be needed. In case an indigestion is present, it should be treated 
according to the type discovered. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in 1 drachm (4.) doses three times daily in 
sweetened water (Da Costa); copaiba; sodium nitrite (J. P. Sawyer); 
strychnin (Guibout) ; sodium arsenate, employed by Blondeau in doses 
of from fa (0.002) to fa (0.0013) of a grain; the fluid extract of ergot 
in \ drachm (2.) doses (Morrow 7 ); atropin sulphate in doses of -fa 
(0.001) of a grain (Schwimmer) ; and sodium salicylate in 20 grain 
(1.33) doses. The latter drug has been praised highly by a number of 
writers. It is frequently given in 1 grain (0.06) doses every hour. 
Quinin is of value even in cases w^hich are not malarial. Aspirin in 



URTICAR1 I I 7."i 

5 grain doses (0.33), given from three to five times daily, Is al o of 
distinct value. Pilocarpin, or the fluid extract of jaborandi, is known 
to produce at times a powerful effect in relieving surface congestions 
of the skin by means of the sweating it occasions. 

Schwimmer endorses the following formula for this affection: 



1$ — Atropine sulph., 




gr. \ 


A(|. deal ., 






( Hycerin., 


aa 


."-: 


Gum. tragacanth., 




<1. B. 


Ft. pil. Xo. xx. 







01 

M. 



When urticaria is due to such disorders as malaria, gout, or dia- 
betes, the relief of the urticaria depends upon the eradication of the 
original disease. An appropriate treatment should be instituted with 
that end in view. 

In the local treatment of urticaria, protection of the sensitive skin 
from all sources of irritation is the chief object. The complete cover- 
ing of the affected region with absorbent cotton will often cause a 
rapid disappearance of the symptoms. Individual lesions which are 
sealed with collodion or plaster usually disappear promptly. The 
zinc-oxid adhesive plaster is very serviceable, as it does not irritate 
the skin as a rule. The patient's underclothing should be of soft linen, 
cotton, or silk, and to prevent friction with the skin a dusting-powder 
may be used freely, both on the skin and in the meshes of the under- 
wear. Sleep should be secured without an excess of bed-covering, and 
places where the temperature is for any reason elevated should be 
carefully avoided by the patient, such as proximity to a fireplace 
or a drop-light, heated places of amusement, or the kitchen. 

Great diversity exists in the methods employed to assuage the dis- 
agreeable sensations experienced in the skin. As a rule, some anti- 
pruritic application is necessary, the following apparently giving best 
results: phenol, in the strength of | to J of 1 per cent., in a lotion; 
dilute hydrocyanic acid in the strength of i to 1 per cent.; menthol 
in the strength of \ to 1 per cent., in an ointment; camphor, in the 
strength of from 10 to 15 per cent., in a dusting-powder. 

The diversity of method is explained by the varying results obtained 
in different patients after the application of the same medicinal agent. 
Thus: cold and hot water-baths; baths medicated by marine salt; 
aromatic vinegar, alcohol, cologne, camphor, the alkalies, and sulphuric 
ether (compresses dipped in such solutions and laid over the part 
affected); douches, and vapor-baths will, any of them, in the ease of 
some individuals, produce a marked alleviation of symptoms, and in 
others will be either inoperative or actually serve to aggravate the 
symptoms to the highest degree. Ilebra asserts that several of the 
baths named above are useless, while Kaposi recommends cold lotion- 
medicated with aromatic volatile substances. Fox prefers that alco- 
hol, or cologne-water to which benzoic acid has been added, be dabbed 
over the part and permitted to evaporate. Solutions of menthol in 



174 HYPEREMIAS AND INFLAMMATIONS 

alcohol and water, 1 part to 500 or 600, operate similarly. Ilillairet and 
Gaucher employ in a similar way a solution consisting of one-third of 
ether and two-thirds of warm water. 

The alkaline hath should contain sodium carbonate, sodium bibo- 
rate, alum, or potassium bicarbonate, either singly or in combination, 
in the strength of about 6 ounce- | ISO.) of the salt to 30 gallons of 
water; 1 or 2 ounces (30. 00. | of potassium sulphuret may he substi- 
tuted. The water is made demulcent by the addition of starch or of 
gelatin, or by immersing in it a muslin bag containing bran. When it 
is desired to employ the acid hath, ] ounce i 1."). i of either hydrochloric 
or nitric acid i- added to the quantity of water given above. The hath 
of this size may also he medicated with I drachm I L) of corrosive 
sublimate; or this drug may be used as a lotion in the strength of 
from j (0.016) to J (0.033) grain to the pint (500.). Phenol, benzoic, 
salicylic, boric, dilute' hydrocyanic, and dilute nitric acids in weak 
solution are also employed with advantage in some cases. 

Other external applications are thymol, ammonium carbonate, potas- 
sium bromid, ether, chloroform, or chloral-camphor in the strength 
of \ to 1 drachm 2. I. to the ounce (30.) of ointment. This latter 
substance is prepared by rubbing together equal parts of camphor and 
chloral until a semiliquid roults. The preparation is an antipruritic 
remedy of value, hut if not largely diluted will increase the uneasy 
sensations produced. In other cases an oily or fatty substance will 
give more prompt relief, especially if the eruption has been irritated 
by scratching and tends to persist. Among useful applications may 
he named the linimentum calcis of the pharmacopoeia and cold-cream 
salve, to which may he added fluid extract of grindelia robusta, 1 part 
to 20 or 30 of vehicle; also the dusting-powders, which are described in 
the chapter relating to ( reneral Therapeutics. Among these Anderson's 
dusting-powder i> valuable: 

1$ — Pulv. camph., 
Pulv. zinci oxidi, 
Pulv. amyli, 

These powders are the most cleanly of all external applications in 
urticaria, and are often the only local measures required. Amoii"' the 
Germans, sulphur, naphtol, and tar-salves are employed in the manage- 
ment of the disease. 

One of the most effective and trustworthy of local applications in 
severe urticaria is a starch solution. The starch is first mixed with 
cold water, and is then boiled until the solution is of the consistency of 
thin mucilage. To each pint of this 1 drachm (4.) of zinc-oxid and 
2 drachms (8.) of glycerin are added before ebullition is completed. 
When cool and applied to the surface this solution often gives prompt 
relief. The same is true of a thin solution of boiled oatmeal. 

Frequently a change of residence and climate, with a variation in the 
routine of life and new social surroundings, is of value. The various 
mineral springs, both in America and abroad, have been visited to 



5jss; 


6 


5ss; 


15 


5j; 


30 



URTICAR1 I 170 

advantage, largely for the reasons mentioned above. Thus, the 
Karlsbad, Vichy, Saratoga, and White Sulphur Springs have all been 
credited with the production of beneficial effects in urticaria. 

In lichen urticatus particular care must be exercised in outlining a 
diet suitable for the child. The elimination is important, and all 
sources of possible irritation must he sought out and eliminated. In 
severe cases an anodyne is necessary at night, and Fox advises opium 
or chloral. Internally, rhubarb and bicarbonate of sodium are of 
service. Locally, in addition to any of the above-mentioned topical 
applications, Fox recommends: 



1$ — Hydrarg. chlor. cor., 




grs. jss; 




075 


Chloroform i, 




TTL xx; 


1 


20 


Glycerini, 




Sij; 


60 




Aq. rosse, 


q. s. ad. 


ovnj; 


240 








Prognosis. — The prognosis in an attack of urticaria, as may be 
seen from what has preceded, is exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest traces of his trouble. In the 
case of children, the attack is often at an end in the course of twenty- 
four hours. 

It should, however, never be forgotten that urticaria may torment 
the life of a patient to the utmost bounds of tolerance and seriously 
impair the general health. Persistent and rebellious chronic urticaria 
may prove to be a truly formidable affection. 

Urticaria Pigmentosa 1 (Xanthelasmoided). — Urticaria pigmentosa is 
among the rare diseases, although a large number of cases are now 
recorded. It has been noted in all large centres of population, and 
unquestionably a great many cases have been seen and more or less 
studied without being reported. The disorder was first described by 
Nettleship, in 1869, and its present name was given by Sangster, in 
L878. Blumer, in 1902, compiled 83 cases, and in 1905 Little collected 
additional ones, making a total of 154, and many more have appeared 
since. 

Symptoms. — The disease, as a rule, begins in the first year of life, 
though many true examples have occurred at a later date. According 
to Little's statistics, 70 per cent, appeared before the end of the first 
year. The early lesions may be urticarial, occasionally bullous, or of 
the type which is characteristic of the disease, which is exhibited as a 
pigmented macule or nodule. The disorder is described as occur- 

1 For bibliography incorporating practically all the recorded cases, sec Blumer (Monats- 
hefte, L902, xxxiv, p. 213, with a review of tin; clinical and pathological features of 
the disease); Reiss (ibid., 1903, xxxvii, p. 93) ; Duhring's Cutaneous Medicine, vol. ii, 
p. :*<)<>; \\.»llf (Mradek's Bandbuch, i, p. ."><>«>>; Perrin (La Pratique derm., iv, p. 772); 
E. Graham Little (Brit. Jour. Derm., 1905, xvh, pp. ;>.">:>. 393 and 427; and ibid., L906, 
xviii, |). L6. A thorough exposition of the subject, with a report of l I eases, with his- 
tology and :i review <>f the recorded English, German, Austrian and French cases, a total 
of 154); Knowles (Trans, of the Amer. Derm. Assoc., 191 I. A report of four eases and 
a special study of the histology, with bibliography); Thin, Hoggan, and Fox (quoted by 
lama, p. <)55). 



176 



HYPEREMIAS AND INFLAMMATIONS 



ring in three types; first, those exhibiting plane or macular lesions; 
second, those which are distinctly nodular or tubercular; and, third, 
mixed varieties. Of 121 cases collected by Little in which the type 
was indicated in the description, 83 were of the macular, 10 of the 
nodular, and 28 of the mixed type. The lesions vary in color through 
all the shades of brown, yellowish-brown and reddish-brown. When 
irritated they become reddened and temporarily lose some of the 
brownish shade. Occasionally, in the nodular variety, a zone of redness 

Fig. 44 




Urticaria pigmentosa with xanthoma-like lesions. 



surrounds the brownish discoloration. The lesions vary in size, and, 
according to Little, are from split-pea- to coin-sized and larger, and 
as a rule are uniform in size in a given patient, the macular variety 
presenting larger lesions. In shape they are oval or circular. While, 
as a rule, the lesions remain discrete, they may coalesce and form large 
patches, more commonly in the macular variety, when by fusion irreg- 
ular figures are formed, and in certain cases large areas of the cutane- 
ous surface become involved. While there is no special distribution 



URTICARIA 171 

of the lesions, the trunk, especially over the hark, may be most exten- 
sively involved. Occasionally, they spread to and involve the neck, 
face, scalp, palms and soles, and the buccal mucous membrane and 
palate. On the mucous membrane of the mouth Little describes 

small, brownish-yellow, slightly raised patches, which were devoid of 
subjective sensation. As these were not examined histologically, he 
was not certain that they were true lesions of the disorder. The lesions 
vary in number from a few to a great many. Little describes a case 
with but two lesions, and Colcott Fox 1 one with less than a dozen 
macules. Another case of widespread dissemination is described in 
which the greater portion of the cutaneous surface was involved. The 
lesions usually develop rapidly and then remain for long periods of 
time, the pigment in most cases being permanent. Fresh outbreak- 
occur at irregular intervals. One ease is recorded of fifty years' dura- 
tion. As a rule, no sequels other than the pigment are left, but in a 
moderate number of cases sears have been noted. The surface of the 
macules is smooth, while that of the nodules may be corrugated and 
roughened. An important clinical manifestation is the reddening, 
swelling, and enlargement of the pigmented lesion when irritated. 
This phenomenon does not occur in any other of the pigmented dis- 
orders. The subjective sensations may be marked, moderate, or 
absent. In a number of eases itching is not a prominent feature. In 
consequence of this, the general health is but little affected in most 
cases. As a rule, dermographism is present, even in cases not subject 
to itching. General enlargement of the glands was noted in a number 
of cases, even in those in which itching was absent. The glands are 
described as being hard and shotty, and resembling those found in 
syphilis. In one of the author's patients the lesions closely resembled 
those of xanthoma, and the diagnosis was only made after a histological 
examination. 

Etiology. — The cause of the disorder is unknown. It occurs more 
frequently in fair than in dark people. The male sex shows a greater 
number of cases. Several incidents have occurred which have been 
attributed as factors in the production of the disease, but these may 
have been coincidences. The disorder has been seen to follow vacci- 
nation, varicella, and measles. Rarely a shock to the nervous system 
has apparently been a factor. Hutchinson was of the opinion that 
insect-bites were responsible. In one case, the eruption appeared 
after a sulphur-bath. In another, the administration of morphin 
injections to the mother during pregnancy was believed to be the 
exciting cause. Xeisser believed the disease to be allied to the nevi. 
Little states that it seems to be a justifiable inference that there i- a 
general tendency, probably congenital, to over-production of mast- 
cells in the skin of patients suffering with urticaria pigmentosa. The 
local excessive accumulation, clinically represented by macules or 
nodules, may be determined, as the clinical experience would indicate, 

1 Allbutt and Rolleston's System of Medicine, Oil, ix, p. 236, 



178 HYPEREMIAS AND INFLAMMATIONS 

by various accidental phenomena: vaccination, varicella, urticarial 
lesions, and even an emotional stimulation, such as fright, acting upon 
a skin already fundamentally abnormal. lie further states that, inas- 
much as uniform blood-changes were found in his cases, the disease is 
probably a congenital blood-disorder of the same class as hemophilia, 
pernicious anemia, and lymphadenoma. 

Knowles believes it is due to a toxin of unknown nature acting upon 
a congenitally abnormal skin, and that the disease should he dissociated 
from urticaria. 

Pathology. The histological changes found in this disorder are 
characteristic. They wen 1 described early by Iloggan. Fox, and others, 
but the character of the cells was not recognized until the classical 
description given by lima in 1887. At that time, discovery was made 
that the cellular infiltration was composed of mast-cells, and it is the 
presence of these in large numbers that produces the characteristic 
histological picture. According to Unna's early description, these cells 
arc' found in the coriuni, distending the papillary body and flattening 
the epidermis above. They are closely packed, mast-cell to mast-cell, 
and arranged in columns by the persistence of collagenous tissues, 
between which, when spastic edema is added, wide lymph-spaces open. 
In his early work Dnna believed these to be migrated wandering-cells, 
but later decided that they developed locally from connective-tissue 
cells which had taken up mast-cell granules. In the epidermis, aside 
from more or less 31 retching and flattening, no other changes were 
noted, except an increased amount of pigment in the basal layer of the 
rete. Tuna's findings have since been confirmed by practically all 
observers, early among whom should be mentioned Baumer, 1 Gilchrist, 2 
and Brongersma. 8 More recently Little, 4 Knowles, and others have 
made a particular study of the histopathology of the disease. 

In addition to the rows and columns of mast-cells found between 
the collagenous bundles, cells are also found about the blood-vessels, 
hair-follicles, and sweat-glands, and granules from these cells may be 
occasionally detected lying free in the lymphatic spaces of the corium 
and subcutaneous tissue. The cells are cubical and fusiform in shape, 
but aside from their special arrangement present no peculiarities. The 
collagen-bundles are separated and spaced out, especially in the super- 
ficial part of the corium, and the elastin shows a similar arrangement. 
Little states that the pigment is found in special cells in the basal layer 
of the epidermis, and that these extend upward and invade several 
superimposed layers of the rete. The same cells may be seen free in 
the corium, usually near the basal layer of the epidermis. The amount 
of pigment is variable, and, according to Little, the color of the lesion 
depends upon the number of mast-cells as well as the amount of pig- 
ment. Gilchrist and Little found mast-cells in apparently normal 
skin in these cases. The blood-vessels of the corium appear to be 

1 Archiv, 1896, xxxiv, p. 323. 2 Johns Hopkins Hosp. Bull., 1896, vii, p. 140. 

3 Brit. Jour. Derm., 1899, xi, p. 179. 

4 Loc. cit. 



URTIC w.7 i 179 

increased in number and are dilated, and it is about these tinctures 
thai the major portion of the cellular infiltration occurs. Edema is 
described by a number of observers throughout the whole cutis, with 
dilatation of the lymph-spaces about the vessels and glandular struc- 
tures. Little also found an intracellular and occasionally an inter- 
cellular edema in the epidermis. Dnna believed the brown color of 
the lesion was due to the ordinary pigment of the epidermis, which was 
increased in the basal layer of the rete; l>nt according to Little's obser- 
vations the pigment occurs in special cells situated not only in the basal 
layer but above it, and also a few in the corium, and he repeatedly 
demonstrated the granules of pigment to be melanin. 

Diagnosis. — Urticaria pigmentosa is to be distinguished from the 
slight pigmentation left after well-marked urticaria of later years by 
the beginning of the disease in infancy and by the persistence of the 
nodules. Xanthoma in all its forms is readily distinguished by its 
occurrence in special regions (the eyelids, for example); by its first 
appearance, in most patients, at a later period of life than infancy; and 
by its characteristic chamois-leather-yellow shade. 

Treatment. — Treatment is entirely unsatisfactory. When an urti- 
carial tendency is present, this may be treated in accordance with the 
rules laid down for that disorder. 

Prognosis. — The active reproduction of lesions commonly subsides 
spontaneously after a certain number of years. The hyperpigmen- 
tation may remain indefinitely. Certain cases have been reported as 
having been relieved in a short time, but in the major number the dis- 
ease persists after long periods of time. 

Angioneurotic Edema. 1 — Synonyms: Giant Urticaria (Milton), 
Urticaria Edematosa (Hardy), Acute Essential Edema (Etienne and 
Galliard), Wandering Edema, Quincke's Edema, Acute Circumscribed 
Edema. 

This unusual disorder was early described by Milton, 2 Bannister,^ 
Quincke, 1 and many others. The disease is characterized by circum- 
scribed edematous swellings of the skin and subcutaneous tissues. 
It appears suddenly, lasts from a few hours to a day or two, and is 
accompanied by sensations of tension and by varying degrees of itch- 
ing. It occurs, as a rule, about the face, genitals, and extremities, 
and has a marked tendency to recurrence, often showing an hereditary 
history and continuing its activities through years to a lifetime. 

Symptoms. The lesions appear suddenly, often in the early hours 
of the morning, and may be single or multiple, and of great variation 
in si/e, consistence, color, and shape, depending upon their situation. 
In si/e they vary from one to two inches in diameter on the hands and 
eyelids; while on the trunk and lower limbs large-nut- to orange-sized 

1 For literature, Cf. Index Catalogue of the Surgeon-General's Library, 2d Series, 
vol. xii; and Cassirer's monograph: Die vasomotor-trophischen neurasem, Berlin, 1901; 

also Osier's Modern Medicine, 1909, vi, p. 648; Bullock, The Treasury of linn 
Inheritance, Pari iii, 1909. 

- Edinborough Med. Jour., 1878. 

8 Chicago Med. Review, June 20, 1880. ' Monatshefte, 1882, p L29. 



180 HYPEREMIAS AND 1 XELAMMATIONS 

globular tumors are seen. Osier describes swellings on the hands as 
large as light-weight boxing-gloves, and saucer- to plate-sized swell- 
ings on the trunk and thighs. On the eyelid and lip the author has 
seen, in common with many others, swellings of such size as entirely to 
distort the features of the patient. In color the lesions may he of the 
normal hue of the surrounding skin, opaque-white, translucent, or waxy- 
looking, or of a slightly yellowish tinge; or they may he reddened in 
varying degrees. The local temperature may be normal or subnormal. 
In consistency the lesions are firm, elastic, and at times hard. On 
the eyelids the lesions are softer, and pitting may he detected; in the 
declining stages in other situations the lesions become softer, and after 
their disappearance the skin may he flabby and wrinkled. The over- 
lying skin is smooth and shining, and in certain cases bullae may form 
(Osier). As a rule, the lesions occur asymmetrically, though a sym- 
metrical arrangement may he noted on the hands, and occasionally 
the whole face max he involved. The areas of predilection are the 
face, genital region, and extremities, though the trunk and other situa- 
tions may he 1 attacked : the mucous membranes of the mouth, pharynx, 
larynx, the accessory sinuses and other portions of the upper air 
passages, the gastro-intestinal mucosa, and the conjunctiva. Edema 
of the glottis produces alarming symptoms and numerous fatalities 
are recorded from this involvement. A remarkable example of this is 
portrayed by Osier I p. 655). 

The progress of the disease is marked by recurrence of lesions, fre- 
quently in the same situations, through a period of years. In a patient 
under observation for some years the lesions constantly recurred on 
the tongue, upper lip, eyelid, and dorsum of the hand. The swelling 
remained for several hours to one day and was intense. 

Subjective symptoms are usually noted only in the feeling of ten- 
sion, with moderate itching or sensation of heat. As a rule, there are 
no constitutional symptoms, though concomitant attacks of colic have 
not infrequently been noted. In ten of Osier's cases colic was present, 
and he cites examples in which abdominal operations have been per- 
formed for erroneously suspected appendicitis, gall-stone, or renal 
colic. 1 In addition, there may be various grades of indisposition (head- 
ache, dizziness, and depression) as accompaniments. In other cases 
there have been noted hemoglobinuria, albuminuria, and various cuta- 
neous eruptions belonging to the urticarias, erythemas, and purpuras. 

Etiology. — The affection occurs most frequently in early adult life, 
and is rare after the sixtieth year. Fox 2 records an example occurring 
at the age of three months. All writers agree that the disease occurs 
most frequently in people of the private-patient class. Relative to 
sex, the disease occurred in 14 females and 4 males in Osier's list of 
18 private cases; while, on the other hand, Collins (quoted by Fox) 
found in a collection of American cases one-third more females, and 

1 Amer. Jour, of the Med. Sci., 1904, exxvii, p. 751. 

2 Allbutt and Rolleston's System, 1911, ix, p. 228. 



URTICAR1 I 181 

Cassirer, 1 in his review of the literature, found the condition rever ed, 
namely, 70 males to 63 females. 

Among predisposing causes various factors arc recorded, such as 
nervous influences, which Osier believes most important, and which 
are exhibited as migraine, neuralgia, exophthalmic goitre, and 
melancholic tendencies. Other factors are malaria, alcoholism, men- 
strual disturbances, emotional disturbances (fright, anxiety, worry), 
overwork, insomnia, and mental exhaustion. Morichau-Beauchant- 
divides the acute circumscribed edemas into three groups: the 
arthritic, the peliotic, and the true angioneurotic edema, and believes 
they have a common cause in gastro-intestinal toxic infection. Schles- 
inger 3 observed the disease associated with erythromelalgia, both 
disorders being induced by over-indulgence in alcohol. Heredity is 
an important factor. Osier 4 recorded its occurrence in 22 people in 
five generations, in which it caused two deaths. Elisor 5 recorded 49 
cases in seven generations, 12 of whom died of edema of the glottis. 
Other much less remarkable herditary examples have been noted. 

Pathology. — The pathogenesis of the disorder is unknown. Its close 
relationship to urticaria is admitted. The local lesion, according to 
Osier, is an extreme urticarial one, with exudation of serum, leukocytes, 
and occasionally red-blood corpuscles. Its relation to the purpuras 
and erythemas is suggestive. 6 

Diagnosis. — In well-defined cases, with recurring large, tense lesions 
occupying the classical regions, the diagnosis is clear. Localized 
edemas from well-known causes must be differentiated, such as those 
occurring in local thrombosis, stasis, infections about the nose induc- 
ing lymphatic obstruction, and the early edematous stage of sclero- 
derma. The lesions of angioneurotic edema are more acute and tran- 
sient, and by a consideration of the accompanying features of other 
disorders are differentiated. The difficulty has occurred particularly 
in those eases involving the gastro-intestinal mucosa, accompanied by 
colic. The symptoms here are erroneously attributed to other dis- 
orders. 

Treatment. — The treatment, in the main, resolves itself into the 
general care of the patient. Careful general systematic examination 
must be made, and all departures from the normal corrected if possible. 
Winfield 7 recorded a case of angioneurotic edema entirely relieved fol- 
lowing successful treatment of cholelithiasis; and Oberndorf 8 reported 
disappearance of the symptoms of angioneurotic edema following an 
appendectomy. In some cases changes in the dietary have been 
beneficial, in others useless. Stimulating, highly seasoned, and indi- 
gestible foods, and spirits are to be interdicted. 

1 Loc. ait. - Annates, 190G, vii, p. 22; abstr. Jour. Cut. Dis., 1907, xxv. p. 130. 

3 Med. klin.. Berlin, 1906, ii, p. 94; abstr. Jour. Cut. Dis., 1907, xxv, p. 129. 
' Amer. .lour. Med. Sci., L888, xcv, p. 362. 
( iu\ 'a Hosp. Reports, L904, Iviii, p. 111. 
" Oshr, Brit. Jour. Derm., 1900, xii, p. 227. 
7 Jour. Cut. Dis., 1907, xxv, p. 217. 
s Jour. Amer. Med. Assoc, 1912, lix, p. G23. 



182 HYPEREMIAS AND INFLAMMATIONS 

Strychnin, quinin, and arsenic, as well as the bromids, ergot, bella- 
donna, the salicylates, and aspirin, are of value. In Osier's experience 
the nitrites and nitro-glycerin, given in large doses, and calcium salts 
were of the most value. 

Prognosis. — The milder cases run a benign course and recover in a 
reasonable time. Others are persistent and troublesome for years; 
while in severe mucous-membrane involvement edema of the glottis is 
always a menace. In 170 cases tabulated by Bullock, death occurred 
from this cause in 36. 

PRURIGO. 1 

Synonyms. Prurigo of Hebra, Prurigo Gravis, Prurigo Ferox, 
Prurigo Agria, Prurigo Mitis. 

Definition. Prurigo is a chronic, exudative, cutaneous affection, 
commonly beginning in infancy or early childhood, continuing through 
life, and characterized, at first, by urticarial symptoms, and later by the 
occurrence on the extensor surfaces of the extremities, and also on the 
trunk, of minute, pale or reddish papules, accompanied by an intoler- 
able itching. The disease formerly was chiefly seen in Austria, but of 
late years has been described in many parts of the world, including 
America. In this country, as a rule, only mild cases arc seen among 
the Dative population. 

Prurigo is one of those terms which in the past have led to consider- 
able confusion in the nomenclature of cutaneous disease, the term 
having been applied to many different affections. It is here limited 
to the disorder originally described by Ilebra under that name, the 
characteristics of which are outlined below. 

Symptoms. — The earliest symptoms are usually displayed, in the 
latter portion of the first year of life, in the form of an urticarial rash, 
which persists, and which is finally succeeded by typical papules of the 
disease. Fox 2 maintains that the initial eruption may be papular 
and not urticarial. These papules are millet-seed- to hemp-seed-sized, 
in color not differing markedly from that of the normal skin. They are 
intensely pruritic, and rapidly become covered with blood-stained 
crusts in consequence of the induced scratching. As a result of this 
trauma, there ensues a long train of complications, including pustula- 
tion, fissures, excoriations, dense infiltrations, crust-formation from 
exuded serum and dried blood, edema, licheniflcation, and diffuse, 
dark-brown pigmentation of the skin-surface in large areas. The 
glands which receive the lymphatic flow T from the excoriated areas 
are enlarged. This adenopathy is conspicuously shown in the inguinal 
and cubital glands. Fully developed, the disease presents in general 
the same physiognomy in patients of different ages. The extremities 

1 Sir Malcolm Morris: Prurigo, Pruriginous Eczema, and Licheniflcation. Brit. 
Med. Jour., June 29, 1912, p. 1469; with discussion (Brit. Jour. Derm., 1912, xxiv, 
p. 251) by r'olcott Fox, Galloway, Leslie Roberts, Whitfield, E. Graham Little, and 
MacLeod. 

2 Allbutt and Rolleston's System, ix, p. 271. 



PRURIGO 183 

always exhibit the severest manifestations of the disease, and of the e 
the leg and forearm are usually affected more severely than the thigh 
and arm; though the trunk, the forehead, the neck, the face, and the 
scalp may also he involved. Ilehra found the disease exhibited with 
increasing severity from the scalp downward. The extensor surfaces 
are invariably selected by the disease, while the flexor surfaces, such 
as the axillae and the groins, except as regards adenopathy, are free 
from change. The general health of the patient manifestly suffers 
from insomnia and nervous agitation induced by the state of the integu- 
ment. Emaciation, malnutrition, and cachexia are common sequels. 
The mental and moral tone of the patient thus harassed from early 
childhood throughout an entire life is necessarily profoundly impaired. 
Insanity and suicide are reckoned among its remote consequences. 

Mild and severe forms of the disease are distinguished under the 
terms prurigo mitis and prurigo ferox or agria; they agree with respect 
to the evolution of symptoms; the only difference to be observed is in 
their intensity. In the former the papules are fewer, the recrudescence 
rarer, the itching less intense, and the amenability to treatment more 
pronounced. Although incessant and judicious treatment, favorable 
climatic influences, and comfortable conditions of life are factors 
which mitigate the symptoms, nevertheless the difference between the 
two forms is probably largely determined by the intensity of the causal 
elements which first establish the disease in the individual. A prurigo 
which begins with severe symptoms may persist in the ferox form 
throughout life; while a prurigo mitis is such from the first appear- 
ance of the disorder. A prurigo-like eruption not infrequently occurs 
in association with lymphadenoma. 

Etiology. — The disease occurs chiefly in Austria, a few cases being 
recorded elsewhere. Wigglesworth, 1 Campbell, 2 Zeisler, 3 and others 
have reported cases in America. The actual cause of prurigo is not 
positively known. It is encountered more often in the male sex, is 
never contagious, and is never induced by lice; but, according to 
Ilebra and Kaposi, it may be grafted upon an hereditary predisposition. 
Several cases have been known to appear in one family, suggesting 
strongly an hereditary element. ''Scrofula," tuberculosis, malnutri- 
tion, "misery," poverty, anemia, and filth are held to be severally 
favorable to its development. Boas, 4 after a series of tuberculin injec- 
tions in twelve patients, concludes that tuberculosis is not a factor in 
the prurigo of Ilebra. The disease is practically limited to the poorer 
classes living under wretched hygienic and social conditions. Some 
authorities, especially among the French, hold that the disease has a 
neurotic base; that the itching is the essential element, the papules 
developing from the irritation of scratching. Others believe that a 
toxic cause operates, because of the urticaria at the beginning and the 
frequency of stomach and bowel disturbances in those who are afflicted. 

1 Anicr. .lour. Syph. and Derm., L873, iv. p. 21. 

»Arohiv. Derm., L878, iv, p. 119. » Jour. Cut. Dis., L889, vii. p. 108. 

1 Nord. ui. -d. Aicliiv, Abt. ii, p. 2 1; abstr. Brit. Jour. Derm., 1912. xxiv, p. 374. 



184 HYPEREMIA* AND INFLAMMATIONS 

It is highly probable that both theories have a more or less true rela- 
tion to tht 1 etiology of the disease. 1 

While typical prurigo i'erox, as described by the Vienna school of 
authors, is rare in America, the opinion is gaining ground that the 
same disease with milder manifestations (prurigo mitis) is much more 
common lure than has been believed. Imported cases from Vienna, 
presenting severe grades of the disorder, were seen by Dr. Hyde in 
his clinic. Cases of the milder type area matter of not uncommon 
record. 

Pathology. Kaposi practically admits that, striking as is the clinical 
portrait of tin- disease, its anatomical features arc indistinguishable 
from severe form- of obstinate papular eczema, or from other forms 
of chronic dermatitis accompanied by hyperplasia. The micro- 
scope reveals proliferation and swelling of rete-cells, cell-infiltration, 
and edema of the papilhe, most marked around the vessels, and fre- 
quently dilated lymph-spaces. There is a scattered deposit of pig- 
ment in the corium, and many cutaneous muscles (erectores pilorum) 
are thickened and shortened. Holder- states that these muscles are 
not only hypertrophied, but also are contracted, and that the papule 
ha- an urticarial basis. 

Some authors contend that the papules are solely due to traumatism 
of the pruritic skin. Auspitz believes that the disease is in fact a 
scnsori-inotor neurosis without an essential lesion. Riehl 3 considers it 
as a chronic form of urticaria. Leloir and others find the prurigo- 
papule Invariably resulting from a cystic degeneration of rete-cells, 
thus forming a cavity, which at first contains clear serum, with the 
addition later of epithelial debris. The walls of the cyst later undergo 
keratini/ation. 

Bernhardt, 4 after studying a typical ease in a patient with a paralyzed 
arm, believes the disease is a dystrophy of the corium due to chronic 
irritation of the trophic centres, and that the papule precedes the 
itching. 

White,"' in a review of the subject which sets forth the great diversity 
of opinion as to the nature and cause of prurigo, concludes: "I cannot 
go farther than accept the existence of a condition of early childhood, 
allied to pruritus and urticaria in its visible manifestations, and not to 
be distinguished positively from them in its first stages, often becom- 
ing in certain parts of the world a chronic affection due to some inex- 
plicable national cutaneous traits, or inherent customs of living; a 
condition which certainly lacks many of the essential elements of indi- 
viduality." 

Diagnosis. — Remembering the extreme rarity of prurigo in America, 
it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, by the course of the disease, by 
the age of the patient when it is first developed, by the great extent of 

1 Matzenauer, Mracek's Handbuch, Bd. ii, pp. 701-714 (with bibliography). 
? Jour. Cut. Dis., 1901, xix, p. 489. 3 Vierteljahr, 1884, xl, p. 41. 

4 Archiv, 1901, lvii, p. 175 (bibliography). 5 Jour. Cut. Dis., 1897, xv. p. 2. 



PRURIGO 185 

the eruption, and by the uniform type of its le ions. In prurigo, also, 
the fingers and the toes, the flexor aspects of the extremitie . and tl e 
face are more or less spared. Under treatment eczema commonly 

yields, at least in some portions of the skin, while prurigo does not. 

From pruritus, prurigo is readily differentiated by its general physi- 
ognomy and history, by its peculiar pigmentations and infiltrations, 
and by the special regions chiefly affected. Eczema may occur coin- 
cidently with prurigo, as a result of the scratching induced by the 
intense itching present in the latter disorder. In pediculosis corporis 
the parasites usually will be found upon the underclothing, and the 
lesions induced by the finger-nails never form closely-packed papules 
There is something highly characteristic in the widely separated 
excoriations, the puncta from wounds inflicted by parasites, and the 
inflamed papules seen upon louse-bitten patients. 

In scabies the characteristic burrows of the parasite will usually be 
recognized, as also vesicular and pustular lesions. Urticaria can be 
mistaken for prurigo only in the earlier stages of the last-named disease. 
From lichen urticatus a period of observation may be necessary to make 
the differentiation. 

Treatment. — In Vienna, sulphur, naphtol, tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occa- 
sionally served to ameliorate the severe symptoms of the disease. 
Mercury, ichthyol, salicylic acid, phenol, boric acid, and diachylon 
and zinc ointments may also be employed upon different portions of 
the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur and 
green soap, has proved of special value in many cases. Vleminckx's 
solution (q.v.), followed by hot bathing, and corrosive-sublimate 
baths, 1 drachm (4.) of the sublimate to 30 gallons of water, has also 
been recommended. Fox 1 reports a case relieved with sulphur and 
ichthyol ointments. Internally arsenic has proved valueless, while 
phenol occasionally has seemed beneficial. Cod-liver oil and the 
ferruginous tonics with the bitters are indicated in many patients suf- 
fering from malnutrition. A generous diet and a tonic regimen are 
often essential to the management of the disease. It is to be noted of 
all cases that they are influenced happily by the warm weather of the 
summer season and by special attention to cleanliness and hygiene. 

Prognosis. — The disease usually persists through life. The most 
favorable conditions are those in which the patient is young and sur- 
rounded by circumstances which permit of provision for his needs. 

Prurigo Nodularis. — Synonyms: Multiple Tumors of the Skin 
Accompanied by Intense Pruritus; Urticaria Perstans Verrucosa. 

Definition. — In the year 1880, Ilardaway, 2 of St. Louis, described 
this rare disease, which occurred in a female patient under his care, the 
histological study being made by Ileitzmann. In 1906, Schamberg and 

1 Jour. Cut. Dis., 1903, xxi, pp. 1 IS 220. 

2 Now York Jour. Derm., April, 1SS0: Trans. Amor. Derm. Assoc, ls7!». p. 78. 



186 HYPEREMIAS AND INFLAMMATIONS 

Hirschler 1 described two cases of a similar character occurring in negroes. 
In 1908, a similar case was seen by Dr. Hyde, and the above title 
applied to this group. Zeisler, 2 in 1912, made a clinical and histological 
report of a similar case, and brought together several other cases de- 
scribed in the literature under other titles, the chief of these being 
Urticaria perstans verrucosa. He included also White's case of Lichen 
obtusus corneus,* In the case presented before the New York Derma- 
tological Society in 1009 by Dr. Jackson 4 as "Multiple tumors asso- 
ciated with itching," Dr. Johnston stated that the general appearance, 
behavior, and histological character justified its assignment to the 
prurigo group. 

Symptoms.- The disease appears to occur chiefly in adults, and 
usually in women. The lesions are nodular and verrucous in type, 
firm, pea- to finger-nail-sized, occurring in great numbers on the back, 
but chiefly over the extremities, hands, arms, feet, legs, and thighs. 
'! he smaller are at fir-t covered with a smooth envelope, whitish, 
pinkish or brownish (blackish on the negro skin) in color. As they grow 
older they become rough, acquire a horny consistency, and often 
develop at the summit a verrucous condition. After scratching, which 
is practised in all cases, the surface of the nodule becomes furrowed, 
fissured, and at times hemorrhagic. In some instances the nodules 
become fused in a plaque of infiltration; in others they are isolated 
throughout. In one case they began ;is "blisters;" in all the others 
as dry papules. Itching in all cases is severe and appears to be limited 
to the lesions, and seems to he an essential feature of the disease. 

The course of the disease Is c.\< eedingly slow, lasting from fifteen to 
twenty or more years. In some cases not a single lesion has disap- 
peared after its development, and in others recurrence has happened 
after extirpation. That the nodules are not due to trauma from 
scratching was demonstrated in several cases. 

Etiology and Pathology. — The nature of this rare disorder is obscure. 
The description of the histological changes in all the cases corresponds 
closely; the chief changes noted being hypertrophy of the epidermal 
layers, particularly the stratum corneum; vascular dilatation, peri- 
vascular cell-infiltration of the corium, with proliferation of the fixed 
connective-tissue elements. Mast-cells were described in excess in the 
case of Schamberg and Hirschler. Johnston 5 stated that in his case 
Dr. Welch, of Johns Hopkins, discovered that the infiltration lay par- 
ticularly about the nerve-trunks, which fact would account for the 
intense itching accompanying the lesions. Johnston further found at 
times a superficial intraepidermic vesicle, similar to that found inprurigo. 

Treatment. — No treatment as yet practised has been effective. In 
Zeisler's case temporary benefit was obtained by the combined use of 
.r-rays and a 10 per cent, chrysarobin varnish. 

Prognosis. — The prognosis is unfavorable as regards the comfort of 
the patient and the complete removal of the lesions. 

1 Jour. Cut. Dis., 1906, xxiv, p. 151. 2 Ibid., 1912, xxx, p. 654. 

3 Ibid., 1907, xxv, p. 385. 4 Ibid., 1909, xxvii, p. 39. s Ibid., 1912, xxx, p. 659. 



ECZEM l 187 



ECZEMA. 



Synonyms. Ger. Eczem.; Fr., Eczema. 

Definition. Eczema is an acute, subacute, or chronic inflammation 
of the skin, beginning as an erythema, or by the appearance of iso- 
lated or grouped papules, vesicles, or pustules, occurring in uniform, 
multiform, or modified types upon a reddened, generally infiltrated 
base; accompanied by more or less intense itching and burning sensa- 
tions; resulting in catarrhal symptoms and crusting, in infiltration and 
scaling; and leaving, after complete resolution, no cicatrices. 

Eczema is distinctly a protean disease. It is difficult, therefore, to 
define or describe it satisfactorily in a single paragraph. It is not 
only protean in its clinical manifestations, hut its causes are varied, 
numerous, and usually complex. In histological detail different types 
of eczema vary considerably, yet all probably result from one common 
pathological process. Clinically, though a dozen successive cases of 
eczema may present wholly different pictures, yet they all have some 
characteristics in common, and the diagnosis in most cases is not diffi- 
cult. It has often been described as a catarrhal inflammation of the 
skin, but while it is true that as a rule eczema shows at some time in its 
history more or less serous discharge, either in vesication or in a de- 
nuded, oozing surface, many cases of the erythematous or papular type 
persist as such throughout their entire course, and never produce an 
exudate upon the surface. From a clinical standpoint eczema cannot, 
therefore, be regarded as invariably a catarrhal disease. 

A vexed and unsettled question among dermatologists is the relation 
of eczema to other forms of dermatitis. The study of the exact patho- 
logical changes in the skin has led to the inclusion under eczema of 
conditions formerly considered distinct affections. On the other hand, 
many writers, especially in England and France, are now endeavoring 
to exclude from eczema every dermatitis for which a definite cause can 
be found. Eczema is a dermatitis, and it is not possible to say for every 
case which title is the more appropriate. A convenient arbitrary 
division, which is followed in these pages, classes under dermatitis 
those forms of inflammation of the skin which result from recognized 
external causes, and which subside on the removal of the cause. Such 
definite and independent affections as dermatitis herpetiformis or 
dermatitis repens are, of course, considered separately. 

Symptoms. Eczema is characterized by heat, redness, itching or 
burning sensations, infiltration of the skin, weeping or moisture at 
some stage, and multiform lesions. The surface involved in typical 
eczema always shows some elevation of temperature, slight in chronic, 
but in acute cases possibly exceeding 105.5° F. (41° C). Redness, 
varying in shade from the bright rv(\ of the acute to the dull red of the 

•For ;i complete presentation of the subject, with full bibliography, the reader is 
referred to the chapters on Eczema, by Besnier, in I. a Pratique Dermatologique, 

t. ii, pp. 1 to 306, and by Tuna, in Miarck's I landhuch, Bd. ii, pp. 1<>!> to 393; also 
Duhring's Cutaneous Medicine, l't. ii. pp, .'ill to 120. 



188 HYPEREMIAS AND INFLAMMATIONS 

chronic forms, is a feature of the eczematous skin. Itching is prac- 
tically always present and may vary from a slight annoyance to an 
intolerable distress. It is commonly intermittent or paroxysmal in 
character and is usually worse at night. In some instances, especially 
in acute and erythematous types, the sensation of burning or smarting 
may be more marked than that of itching. Occasionally, an eczematous 
skin is hyperesthetic and exceedingly sensitive to contact with even 
the blandest substances. The degree and character of the subjective 
sensations in eczema depend largely upon the location, type, or severity 
of the disease, but also to some extent upon the general condition or 
peculiarities of the individual. In acute types of eczema there is often 
some edematous swelling, together with slight infiltration of the skin. 
In chronic forms the infiltration and thickening of the skin are more 
pronounced and may be excessive. 

The serous discharge which is present during at least a part of the 
course of most eczemas is characteristic, and stiffens articles of clothing 
on which it dries. It may be imprisoned in vesicles, but more com- 
monly oozes from a denuded surface or from minute excoriated points 
which represent abortive or ruptured vesicles. 

Aside from some cases of erythematous and papular eczema, which 
may persist throughout without change of type, eczema is notably a 
polymorphic disease, presenting in irregular succession, or in varied 
combinations, erythema, papules, vesicles, pustules, crusts, scales, 
fissures, excoriations, or denuded and oozing surfaces. 

In addition to the symptoms of heat, reduces, itching, or burning, 
and swelling or thickening of the skin, found in every case of eczema, 
the great majority of eczemas have certain characteristics in common. 
The course of the disease is capricious; not only does the severity of the 
process change frequently and rapidly, but often the type of lesion as 
well. This is most conspicuous in children and in others having delicate 
skins, and in those cases in which the affected areas are not protected 
from atmospheric and other external influences it is unusual for eczema 
to pursue an even course. Daily variations in severity, with or with- 
out change or modification of type, are not uncommon. Apparent 
recovery is frequently followed by a relapse, which may develop fully 
in a few hours and without apparent cause. 

Like other inflammations, eczema may be acute or chronic. The 
acute may precede, and the chronic may follow, or the reverse may 
occur. The disorder originating in subacute or insidious forms may 
become chronic, and then, as the result of fresh or of more severe irri- 
tation, may develop the most acute symptoms. Frequently, as in the 
eczema of children, the disease may be chronic in respect to duration, 
yet most of the time present acute symptoms. As a rule, eczema does 
not undergo spontaneous recovery, but tends rather to remain indefi- 
nitely and to extend either by involving contiguous surfaces or by 
developing in new areas. The disease is commonly more or less local, 
appearing in one or several irregular and usually ill-defined areas, 
but it may be general or even universal. It apparently occurs inde- 



ECZEM I 189 

pendentl.y of all other disorders, the general health remaining unaffected 
even in severe forms of the disease; or it may be the externa] expre - 
sion of constitutional disturbance. 

Clinically, several types of eczema can be recognized. These types 
require separate description. It should not be forgotten, however, 

that in the majority of cases eczema is a complex process, in which 
two or more types are seen, either in succession or simultaneously. 
Though several forms of eczema frequently coexist, it is usual for one 
type to predominate, either throughout the course of the disease or 
for certain periods. 

Eczema Erythematosum is most common on the face, especially in 
individuals exposed to wind and weather or to direct heat, but it may 
appear on any part of the body, and is frequently seen on the palms, 
the soles, and in the genital regions. It begins usually as a diffuse, ill- 
defined area of redness; less frequently as a number of coin-sized 
macules or erythematous spots, which may coalesce or remain more or 
less distinct. Swelling and infiltration are present in varying degrees. 
In acute cases the edema may be excessive, sometimes closing the eyes. 
In the subacute forms, which are the more common, there is less edema 
and more infiltration and thickening of the skin. 

The sensation of itching, which is so characteristic of most forms of 
eczema, is usually excessive, though it may be largely or wholly sup- 
planted by one of heat or of burning. This is especially true when 
the process is acute in character. The color varies from a bright- to a 
dull- or purplish-red, depending upon the severity of the disease, its 
location, and the peculiarities of the individual; and inasmuch as the 
condition is more frequently observed in middle-aged adults, with 
darker hue of integument than in early life, the color of the part is often 
noticed to be of a dull-crimson shade. At times the coloration is irreg- 
ularly distributed, producing a mottled appearance, bright at one 
point and dark at another. A yellowish tinge usually indicates that 
the process is combined with seborrhea, producing the combination 
described in another chapter as dermatitis seborrheica. 

The erythematous surface is modified, as a rule, by more or less fine 
desquamation, which begins a few days after the occurrence of the first 
erythema, and persists to the end of the disease. There is no discharge, 
unless, as frequently happens, the type changes to a moist form. When 
the disease occurs on apposed surfaces, as in the axilla, under the 
breasts, on the interdigital surface of the feet, or about the genitals, 
the superficial epidermis may be destroyed by maceration and friction 
and leave a denuded, oozing surface (eczema intertrigo). 

The disease may pursue an acute course, terminating in exfoliation 
and gradual resolution, or changing to the papular, vesicular, pustular, 
or mixed types. More frequently, the process persists and becomes 
chronic. The skin then becomes more infiltrated and thickened, and 
may present voluminous firm folds, which are very conspicuous and 
often deforming. Exfoliation may be a pronounced feature. 'Flu 1 area 
involved is frequently better defined than in other forms of eczema, 



190 



HYPEREMIAS AND INFLAMMATIONS 



and though the condition may remain limited to its original site for 
months or years, it has a decided tendency to extend either contigu- 
ously or by the formation of new areas. The intensity of the process 
may change frequently and rapidly. It is usually aggravated by 
exposure to heat, cold, or wind, or by any condition which favors con- 
gestion of the part. Scratching of the surface involved produces a 
change in the symptoms which the skilled eye will promptly recognize. 
Minute superficial losses of tissue are then visible here and there upon 
the surface; the more recent lesions having a reddened floor, possibly 
hidden beneath a thin blood-scale, the older being surmounted by a 
light, yellowish-red crust. The scratch-lines, often recognized else- 
where, are here less evident. 

In;. 45 




Eczema nuchae (Lichenification). 



Like all other varieties of eczema, this form is extremely liable to 
recrudescence and relapse. In advanced life traces of the disease may 
be visible for years. 

Eczema Papulosum.— Under this title are classed all those forms 
which have been described as Lichen Simplex, Lichen Eczematodes, 
and Eczema Lichenoides. In exceptional cases eczema may exist from 
first to last as a dry infiltration of the integument. There is perhaps 
no one of the various manifestations of the disease that is so frequently 
confounded with other widelv different affections. 



ECZEM i 191 

The papules arc acuminate, pinhead-sized or larger, colored in vari- 
ous shades of red to a dark lurid shade, and are usually seated upon a 
reddened and infiltrated base. They are generally discrete, though 
often sel closely together; are accompanied by an intense form of itch- 
ing; and of all eczematous lesions are most likely to be irritated by 
scratching. Their summits are torn, often to such an extent as to 
bleed, the blood drying in minute crusts on the apices of individual 
lesions. Existing papules may persist for weeks or may disappear 
and he replaced by others. They may coalesce completely to form 
irregular, thickened, elevated, pea-sized or larger patches, covered with 
scales. The areas involved in papular eczema are often fairly well 
defined in outline. The extent of surface affected varies, the disease 
being in some cases largely diffused over several portions of the body, 
but it is usually limited to small single patches no larger than the 
size of a small coin. Such patches, covered with a single or with 
several groups of reddish papules, may continue to torment the patient 
for long periods of time, or, being at one time relieved, may recur 
with each aggravation of the malady by the exciting cause. Papular 
eczema is a dry manifestation of the disease, and is thus most frequently 
noticed upon the drier portions of the integument. If the moist forms 
of eczema are most frequently seen in early life, it is none the less true 
that the dry forms are the most common in adult life or in advanced 
years. 

The papules here described, when there is free exudation beneath 
the surface, may exhibit pinpoint-sized, vesicular summits, which may 
develop into minute or larger pustules. A patch of papular eczema, 
where no vesiculation or pustulation has been observed, will, if suffi- 
ciently scratched, ooze with moisture, allowing the serum to escape 
from the abraded surface. There are, in fact, few scratched eezein- 
atous surfaces which will not moisten a handkerchief applied to the 
part. This weeping condition attracts the attention of patients them- 
selves. A species of relief from itching is thus obtained; and in aggra- 
vated cases patients will scratch or rub or otherwise irritate the dis- 
eased patches, not merely for the purpose of gratifying the intense 
desire to assuage the itching, but also to induce serous exudation for 
the sake of the relief it affords. 

Resolution of papular eczema is accomplished after the formation of 
scales, the tissues beneath the latter assuming more and more the 
appearance of healthy skin. 

Eczema Vesiculosum. — This type is characterized at an early period 
by t he formation of minute vesicles. It is a matter of importance, how- 
ever, to recognize the fact that the vesicular, like the erythematous, 
is but one of several manifestations of this singularly protean affection. 

The clinical features of vesicular eczema are chiefly due to the acuity 
of the inflammatory process present, and to the consequent free exuda- 
tion of the serum of the blood from the dilated vessels of the coriuni. 
The involved surface usually feels at the outset hot, itchy, or unusually 
sensitive: and soon after becomes more or less intensely reddened, the 



192 HYPEREMIAS AND INFLAMMATIONS 

result of hyperemia and subsequent exudation, which may last for one 
or for several hours. Poppy-seed- to grape-seed-sized vesicles then 
become visible on this reddened base. The lesions may be closely 
packed together, or be discrete, or may be so abundant as to coalesce, 
a frequent behavior of all vesicular lesions. Each vesicle is filled with 
a droplet of clear scrum imprisoned beneath the most superficial layers 
of the epidermis. This vesicle is readily ruptured, and if this rupture 
does not speedily occur as the result of accident, the lesion bursts spon- 
taneously, and its limpid contents are then poured out upon the surface 
of the integument. The quantity of the fluid thus exuded is in excess 
of that originally contained in the small vesicular chambers, due to 
the fact that the excoriated, macerated, and broken epidermis no 
longer presents an obstacle to the outflow of serum from the engorged 
vessels beneath. Minute and even large drops of a clear fluid of syrupy 
consistency can be seer collecting at the points when" the solution of 
continuity has occurred. If with a slip of bibulous paper the first 
drop be removed, its place is visibly filled by a second. Crops of new 
vesicles succeed the first, each drop being followed by the train of symp- 
tom- described. The vesicles are usually short-lived and often have 
disappeared before the patient is seen by the physician. In other 
instances the destruction of the epidermis by rubbing or scratching, or 
by an abundant and rapidly formed exudate, allows the escape of the 
fluid without pn-\ ious vesicle-formation. The discharge dries rapidly, 
when exposed to the air, in light-vellowish oru>ts, which are rarely 
bulky. 

The contour of the affected patch or patches is seldom well defined, 
the pathological portions imperceptibly shading into the sound skin. 
The color of the area thus diseased varies according to the stage of the 
process, being at one time a vivid red, at another yellowish, and when 
covered with crusts or scales undergoing a corresponding change of 
hue. Infiltration of the skin occurs rapidly, so that when a portion of 
the affected integument is pinched up between the finger and thumb it 
is found to be thicker and less elastic than normal. This form of eczema 
may persist or recur in a single small area, or it may spread and become 
diffused or even generalized. It appears commonly on the flexor and 
other surfaces where the skin is thin. 

The subjective symptoms of vesicular forms of eczema are more or 
less intense itching and often burning. In very acute forms there is 
considerable soreness, the patient managing the affected part with as 
much care as if it were a fractured limb. In exceptional cases, more 
frequently observed in children, there is a sympathetic febrile dis- 
turbance of a mild grade. 

As resolution approaches, all the symptoms described above gradu- 
ally decline in severity; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen and fall, and beneath the scales which have taken the place of the 
oozing and broken epidermis a new and tender epithelial covering is 
produced. As a rule, for weeks after the process has completely ceased 



ECZEM I 



L93 



1 1 )<* newly formed epidermis lias ;i slightly reddened and tender appear 
mice, though complete resolution is followed by no permanent sequels. 



I to W 




Eczema pustulosum (infantile) . 
Fig. 47 




L3 



Eczema impetiginosum. (Fox.) 



194 



HYPEREMIAS AND INFLAMMATIONS 



Instead of undergoing resolution, the condition may terminate in 
eczema rubrum, in eczema squamosum, or in eczema pustulosum, this 
last form being ordinarily due to pus-infection. 

Eczema Pustulosum ( Eczem a Impetiginoides; Impetigo Eczematodes). 
—This type may originate in one of the other forms of eczema, in 
consequence of the severity or acuity of the process, or be the result 
of secondary pus-infection; or pustular lesions may rapidly form at the 
on>ct. Usually, there is first seen a crop of minute vesicles, which 
enlarge and become distended with puriform contents. These pustules 
cither accidentally or spontaneously hurst, and the fluid with which 
they are distended dric> into yellowish-green or darker colored friable 
crusts. In aggravated cases the purulent matter seems to form directly 



Fio. l^ 




Eczema pustulosum. (Fox.) 



upon the involved surface. If the process be long continued, infiltra- 
tion occurs, and the itching, which in all varieties of the disorder is a 
characteristic feature, is awakened as an accompanying symptom. 
The itching, however, is rarely of the peculiarly aggravated type 
accompanying the erythematous and papular phases. Pustular 
eczema is most frequently encountered on the head and face, also at 
times on the limbs, particularly about the hair-follicles. It attacks 
those w'ho are debilitated or wdiose resistance is lessened to the invasion 
of pus-cocci. When existing on the face or scalp, there is most com- 
monly an involvement also of the sebaceous glands, the secretion of 
w^hich, altered by the periglandular inflammation, is added to that 
naturally produced by the exudative process. Singular shades of 



ECZEMA 195 

mixed yellow and green and even black are then to be di tinguished in 
the resulting crusts, which later desiccate and fall, leaving a reddened 
and tender new epidermis beneath. 

A particular type attacking the hair-follicles was first described by 
Morris, under the title Eczema Folliculorum. In this form each in- 
flamed follicle projects from the surface in the form of a reddened 
papule, about which the skin becomes hyperemia As the pro< 
spreads centrifugally by the involvement of adjacent follicles, the 
centre undergoes involution, with desquamation and a gradual change 
in color from red to yellow. This condition is found most frequently 
on the extensor surfaces of the legs and arms, in multiple, scattered 
patches. The condition is obstinate, usually recurrent, and may be 
accompanied by intense itching. Morris considers it parasitic in origin 
and allied to sycosis. 

Many examples of pustular eczema belong to a group differentiated 
by Engman 1 and emphasized by Fordyee, 2 designated as Dermatitis 
Infectiosa Eczematoides (cf. this chapter). 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and unmingled forms of 
cutaneous disease, some of them more commonly than others. To 
present, however, a picture of eczema as it is seen clinically, it must be 
understood that these several forms, useful in the analytical study of 
the disease, often become, in actual observation, well-nigh inextricably 
commingled. " Observation of the natural course of an attack of 
eczema," said Ilebra, "furnishes the most unassailable proof of the 
connection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms; in another it is preceded by the 
appearance of red, scaly patches or groups of papules; or vesicles and 
papules are developed together, some of the former rapidly changing 
to pustules and forming yellow, gum-like crusts by the drying up of 
their contents." It is this constant interchange of features that dis- 
tinguishes most eczemas from all other inflammatory affections of the 
skin. 

Eczema Rubrum. — This name has been given to the red and angry 
form of the disease, which, because of the free exudation of serum from 
the surface, has also been termed Eczema Madidans. In this form the 
highly inflamed, intensely red, and wounded integument, the horny 
layer of which has been destroyed and removed, pours out freely upon 
the surface a thick, gummy or syrupy fluid, which, if artificially 
removed, leaves behind it a swollen, angry, and still discharging skin; 
or, being permitted to dry where it has formed, covers the surface with 
large, flake-like crusts, which may be thin and yellow, or thick, dark- 
colored, and often blood-stained. The crusts may remain but a few 
hours before an excessive outpouring of the fluid removes them. There 
are thus displayed in frequent and rapid alteration the discharging and 
the crusted surface. Eczema rubrum may occur on any part of the 

1 Ain.T. Med., 1902 03, iv, p. 7(>(). •Jour. Cut. Dis., 1911, xxix, p. L29. 



19G HYPEREMIAS AND INFLAMMATIONS 

body, but especially in the flexures of joints or where two surfaces are 
apposed; another common site is the legs of elderly people or of those 
who stand much of the time. In this region the disorder is exceed- 
ingly chronic and rebellious to treatment, and eventually is accom- 
panied by a great degree of infiltration and thickening, which may go 
on to hyperplasia and produce a condition simulating elephantiasis. 

Eczema Squamosum I Eczema Exfoliativum). — This type is marked 
by more or less redness, infiltration, and exfoliation of the skin. The 
scales arc usually small, thin, whitish, and adherent. They may be 
scanty or quite abundant. Squamous eczema represents a low grade 
of inflammation, and is present as a transitory condition during a part 
of the period of resolution of all other types of the affection. It fre- 
quently persists, however, in the form of irregular, usually ill-defined, 
more or less infiltrated, dry, scaly patches. It is seen commonly on 
the neck and face, at the border of the scalp, and on the limbs. 

Eczema Fissum (Eczema Rhagadiforme). In eczema of the hand 
the movements of the fingers often produce fissures or cracks in the 
inflamed and infiltrated integument, and to those fissured forms the 
titles named above have been given. Fissures are observed where- 
ever an eczematous disorder has so impaired the elasticity and extensi- 
bility of the skin that it-> necessary movements, especially about the 
joints, tear and stretch the thickened integument. It is thus seen not 
only on the hands, but also on the arms, the feet, and about the ankles, 
the resulting rhagades being, at times, the most painful of all the com- 
plications of the malady. It is seen frequently about the mouth and 
anus. Occurring upon the bodies and the hands of those who are 
compelled to come in contact with irritating substances, this form of 
the disease finds its severest expression. Mild commingled forms of 
squamous and fissured eczema occur quite commonly on the hands and 
faces of persons whose skin is thin, tender, and poorly nourished, or 
exposed to wind, hard soaps, hard water, chemicals, and other irritants. 
The condition is popularly known as chaps or chapping. 

Eczema Craquele. — This is a rare form of eczema described by 
French writers in which a reddened surface is covered with large, thin 
flakes, or scales, separated and outlined in polygonal areas by super- 
ficial cracks or fissures. The condition usually involves a considerable 
surface of the skin, and is accompanied by itching and burning, and in 
most cases by hyperesthesia and an extreme sensitiveness to temper- 
ature-changes. It occurs chiefly in neurotic subjects. 

Eczema Verrucosum. —Eczema verrucosum, or the wart-like form of 
the malady, is occasionally observed, especially upon the lower extremi- 
ties, in middle life or in advanced years, as the result of long-continued 
disease. The integument becomes thickened and so hypertrophied 
as to suggest the appearance of warts closely packed together in a 
circumscribed patch. 

Eczema Sclerosum. — This form is most frequently observed upon the 
palmar and plantar surfaces, and the lower limbs about the ankles. In 
eczema sclerosum is presented a densely thickened, inelastic integu- 



ECZEM I 197 

ment, suggesting the condition of tanned leather, without the occur- 
rence of any of the other lesions of eczema described above. A 8 
consequence, perfect extension of the digits is impaired. 

Eczema Nummularis (Devergie). Eczema nummularis is a localized 
patchy variety, occurring chiefly on the surface of the limbs, particu- 
larly the upper, but also on the trunk, and is characterized by small, 
poorly-defined, erythematous and vesicular patches of rapid develop- 
ment, and by itching and exudation. Under the title Recurrent Eczema- 
toid Affection of the Hands', Pollitzer 1 describes a similar condition 
limited to the dorsum of the hands, and rarely occurring on the extensor 
surface of the forearms. In these round, sharply-defined groups, 
closely aggregated vesicles occur, of an average size of 2 to 3 cm. in 
diameter. The patch rises suddenly, does not increase in size periph- 
erally, is accompanied by moderately severe paroxysmal itching, and 
disappears in a few weeks under appropriate treatment. Relapses 
are common. 

Tuberculous Eczema of Nurslings, so called, is a term which has 
been applied to eczematoid eruptions about the mucous orifices of the 
eyes, nose, mouth, and ears, occasioned and sustained by morbid con- 
ditions of, and serous discharges from, those parts (otorrhea, rhinitis, 
phlyctenular keratitis), and accompanied by edema, vesiculation, and 
enlargement of lymphatic glands. The disease is characterized by 
rebelliousness to treatment and chronicity of course. This disorder 
is improperly named, since tubercle-bacilli have not been recognized 
in its lesions; and because the symptoms above enumerated may all 
be present when there is simply systemic nutritive failure, with no 
tuberculosis of other organs present. 

Eczema Diabeticorum (Fr., Diabetides). — A singularly well-defined 
eczema is to be recognized about the genital organs of those suffering 
from persistent or even transitory glycosuria, due to the irritation 
produced by the passage over the parts of urine charged with sugar. 
Women are often thus affected; and the condition is accompanied by 
the most atrocious itching, excoriations produced by scratching, and 
enormous tumefaction of the ano-genital and surrounding integument. 
The local symptoms are chiefly those of eczema erythematosus, the 
surface being, as a rule, destitute of either vesicles or pustules. There 
are often a profuse serous discharge, considerable infiltration, and the 
production of inflammatory nodules over the engorged surface. 

Eczema Parasiticum. — Under this title is included a large number 
of cases the exact relations of which to the recognized types of the 
disease are still indeterminate. It is well known, for example, that the 
surface of the human body in health is the habitat of an enormous 
number of different parasites, which are, for the most part, harmless or 
are effective as agents of disease only under certain specially favorable 
conditions of the body. Cultivation-experiments with the flora found 
on the eczematous skin have revealed a large number of parasites 

1 Jour. Cut. Dis., 1912, xxx, |>. 710. 



198 



HYPEREMIAS AND INFLAMMATIONS 



which together, if not singly, may be effective in producing some of its 
distinctive features. 

A ringworm fungus ( Epidermophyton inguinale) is responsible for 
the so-called eczema marginatum (described in the chapter devoted to 
Ringworm), also for many cases of eczema intertrigo of the toes. In 

addition, some of the well-de- 
Fig. 49 fined patches of eczema found 

on other parts of the body are 
found to be caused by some 
memberof the ringworm family. 
Infectious eczematoid derma- 
titis described by Engman 1 
and emphasized by Fordyce 2 
occurs ill many forms. It may 
be exhibited as a dry, scaling 
dermatitis, or as large weeping 
areas simulating an eczema 
rubrum, or as crusting patches, 
such as described in connection 
with pustular eczema, or it 
may have all the characteristics 
of an acute vesicular eczema. 
The important feature of the 
disorder is its evident connec- 
tion with pyogenic microorgan- 
isms, inasmuch as antecedent 
abscesses, ulcers, sinuses, or 
other pus-infected conditions 
are found to be in direct causal 
connection. 

Acute Eczema. — An acute 
attack of eczema may be 
ushered in by malaise, chilli- 
ness, or the recognized symp- 
toms of the febrile state. 
With or without these pro- 
dromata, the affected portion 
of the skin-surface becomes 
the seat of a burning sensa- 
tion, w r hich is soon succeeded 
by redness and swelling. This 
tumefaction may occur upon one or upon several portions of the 
body at the same moment of time, and the disease throughout be 
limited to a single area or to several spaces; or it may extend from 
one to other or all regions. This extension may proceed by con- 
tinuous development of the disease along the surface, or an eczema 




Infectious eczematoid dermatitis, following 
ecthyma. (Fordyce.) 



Loc cit. 



2 Loc cit. 



ECZEMA f99 

of the thigh may suddenly be followed by an eczema of the face, 
and this by an eczema of the serotum. Extension of eczema by 

the last-described course may occur when no constitutional cause 
can be discovered and undoubtedly is due largely to the extraordinary 
sensitiveness of the skin when involved in an acute attack, in conse- 
quence of which the slightest irritation produces a new focus of the 
disease at a distant point. This consideration is of special important e. 

The tumid and erythematous surface above described soon assumes 
the features of one or more of the types of eczema outlined in the pre- 
ceding pages. In this manner the evolution of the disease occurs, 
and may continue for weeks, the patient, if unrelieved, being tormented 
by the itching, and, if the disease be extensive, being prevented from 
attending to his usual vocation. Acute eczema of severe grade will 
frequently prostrate a strong adult, confining him to his bedchamber 
and often to his bed. When there is a simultaneous febrile process 
the emaciation and adynamia are proportioned to its severity. Weeks 
and even months may elapse before recovery can be pronounced com- 
plete, subacute patches of the disease lingering here and there upon 
the surface, crust-hidden, scale-covered, occasionally oozing from re- 
crudescence of symptoms. Recovery, even when complete, leaves the 
patient, it should never be forgotten, with a skin sensitive to irri- 
tation and more prone to a fresh attack of the disease than one that 
has been free from such an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade. It 
must be remembered, however, that the process may be mild and sub- 
acute from the beginning, or, again, that a circumscribed patch of skin 
may exhibit all the features of vesicular eczema in an acute form, and 
under the influence of appropriate treatment may be relieved satis- 
factorily in the course of a few days. Lastly, acute or subacute eczema 
may be followed by chronic forms of the disease, the one passing into 
stages of the other by scarcely definable gradations. 

Chronic Eczema. — The symptoms and pathology of chronic eczema 
are largely those of the acute form of the disease. The chief differences 
to be noted relate to diminished intensity of the inflammatory action, 
a marked tendency to recurrence and persistence of the process, and a 
preponderance of scaling and infiltration as contrasted with the active 
secretion and crusting of acute phases. It is important, however, 
to remember that chronic eczema is not only the frequent sequel of 
such acute phases, but is prone, also, to recurrent exacerbations of 
acute grade, during which the serous discharges, consequent crusts, 
and angry aspect of the affected surface do not fail to reappear. The 
itching so characteristic of the malady in all its manifestations is often 
more annoying than in the acute phases of the disease. 

Chronic eczema may involve a limited region of the skin, or may 
invade the entire surface of the body from the head to the feet. Rarely 
thus generally developed, it is more frequently observed upon circum- 
scribed patches of the integument, as, for example, the scrotum or the 
flexor surface of a joint, in which situation it may linger for years or 



200 HYPEREMIAS AND INFLAMMATIONS 

even for a lifetime, now better and now worse, or disappear for brief 
periods only to return with each recurrence of its cause. 

Eczema is one of the diseases of the skin of most frequent occurrence. 
In the statistics gathered by medical men it would seem to rank first 
in the order of frequency, forming from 20 to 40 per cent, of derma- 
tological cases reported. 

Etiology. — The tendency in modern dermatology to regard eczema 
as a dermatitis without obvious cause, or one which persists after the 
withdrawal of a recognized irritant, necessarily places an Increasing 
emphasis upon the importance of etiology. The fact that eczema 
constitute- SO large a proportion of reported skin-diseases emphasizes 
the lack of knowledge of the factors which produce it, and the rapidity 
with which some of these conditions are assigned to other categories 
will he a measure of the progress of acquisition of etiological facts. 

Some diversity of opinion exists among dermatologists as to the 
nature and pathogenesis of eczema. The views held have been grouped 
by MacLeod 1 as follow >: 

1. Parasitic: that eczema is produced by certain organisms acting 
upon the si in. 

2. Toxic: that eczema is the result of the action of irritants, opera- 
tive externally or internally, in a susceptible individual. 

0. Neurotic: that nerve-strain or trophoneurotic influences are the 
efficient cause. 

1. ( utaneons reaction : that eczema is a symptom merely ; a response 
of the skin to irritants without or within. 

Concerning the first hypothesis, most observers believe the dis- 
order, per .sv, to be amicrobic. That bacteria play an important part 
in producing lesions is accepted by all; but these are secondary, though 
the disease may be prolonged by their presence and many lesions be 
produced that otherwise would not be present. That this latter state- 
ment is a fact is often demonstrated by the eradication of the disorder 
by the use of local parasiticides. 

Eczema is a disease of both sexes and all ages. It is not in itself 
hereditary, for no child was ever born into the world with eczema. 
A tendency to the disorder, however, may be transmitted from parent 
to child, though not made manifest until adult life. Eczema may 
occur in individuals who are in every respect superb examples of health, 
but in the majority of cases it is associated with some disturbance of 
the general economy; and it often occurs in persons who are affected 
with many forms of bodily ailment, both acute and chronic. By what 
means these various systemic disorders favor the development of 
eczema is not positively known. Part of their association with the 
cutaneous disease may be considered as coincidence. In some in- 
stances they constitute conditions which favor the production of dis- 
ease in general, eczema not excepted. Their direct influence in the 
production of eczema may be regarded as operating, through the nerv- 

1 Practitioner. 1906, lxxvii, p. 98. 



ECZEMA 201 

ous, vascular, and glandular systems, upon the innervation, nutrition, 

secretion, and physiological growth and repair of the skin. r \ he agen- 
cies by which this is accomplished may f>c considered toxic, whether 

they arise within the system from imperfect metabolism, or are 
developed as the result of microbic invasion. 

Among the conditions which are frequently associated with eczema, 
and which probably stand in causal relation to that disorder, may be 
mentioned the physiological states of pregnancy, lactation, and denti- 
tion; systemic derangements which depend upon defects in digestion, 
assimilation, and excretion; impairment of circulation; gout, rheu- 
matism, diabetes, nephritis, asthma, disorders of the liver, anemia, 
chlorosis, tuberculosis, and syphilis. The number might be extended 
to include all disorders which reduce the general vitality and therewith 
also that of the skin. 

Jacquet and Jourdanet, 1 in an etiological study of occupational dis- 
eases of the hands, conclude that a close association exists between 
digestive troubles and occupational dermatoses, the internal irritation 
being the predisposing factor and the external irritation the exciting 
in these cases. Towle and Talbot, 2 in an investigation of infantile 
eczema and indigestion, found a frequent association of indigestion of 
fats and sugar in the acute exudative types. Hall 3 concludes, after 
a thorough study of the etiology of infantile eczema, that eczema, 
whether occurring in infants or in adults, is a form of reaction or re- 
sponse of the neurocutaneous apparatus to external irritation. Prac- 
tically all observers agree that the nervous system plays a part in cer- 
tain eczemas. Nervous shock and prolonged mental depression are 
considered important factors by Morris. 4 Johnston 5 states that demon- 
strable lesions of the central, peripheral, or sympathetic nervous sys- 
tems are rare in the eezematous person, but admits that shock, fright, 
worry, and fatigue have to be considered etiologically. 

The theory of reflex irritation has been called into service to explain 
the sudden appearance of secondary eezematous lesions at a distance 
from the original focus. The view holds that inflammation of the 
skin is reflected from one place to another through the medium of the 
oervous system. Cases which apparently lend support to the reflex 
theory can be fully explained by assuming, first, an unconscious trans- 
fer of an external irritant from the original site to other portions of 
the body ; or, secondly, a condition of systemic intoxication, which oper- 
ates by so reducing the resistance of the entire skin that a trifling 
irritation at any point is sufficient to produce an eczema; or, thirdly, 
a lodgment within the skin of an irritant, carried to the part by 
the circulation or produced /'// situ through cell-degeneration result- 
ing from trophoneurotic influences. Csillag's 6 experiments show that 

1 Annates, January, 1911; abstr. Jour. Cut. Dis., 1911, xxix, p. 564. 

1 Amer. Jour. Dis. of Children, 1912, x; abstr. .lour. Cut. Dis., 1913, xxxi, p. 54. 

: < Brit. .Jour. Derm., 1905, xvii, pp. 161, 203, 217, and 287. 

1 Diseases of the Skin, 5th Ed., p. 291. '.lour. Cut. Dis.. 1913, xxxi. p. A. 

•Archiv, 1902. Ixiii, p. 213; and Orvosa Hetilap, 1906, 36; abstr. Jour, de Pratic, 
L906, X.». hi. Cf. also Fordyce, Jour. Amer. Med. Assoc, June L3, L903, p. 1621; 
and Pinkus, Mod. Klinik, 1906, No. 9. 



202 HYPEREMIAS AND INFLAMMATIONS 

irritants applied to the skin produce a dermatitis at the area of contact, 
but in no other place, if care be taken to prevent accidental convey- 
ance of the irritant to other regions. He holds that in four-fifths of 
all cases of acute eczema the cause can he shown to be an external 
agent acting upon an over-sensitive skin, and that lack of knowledge 
of the fact lias led to the reflex theory. 

The externa] causes of eczema are identical with those of dermatitis, 
and are chemical, mechanical, thermal, or actinic in their action. As 
stated on a preceding page, no sharp distinction can be drawn between 
eczema and any other dermatitis due to external causes; but those 
forms of dermatitis which persist after the removal of the external 
cause are probably due in part to, and are continued through, the 
action of other etiological factors, and are conveniently classed as 
eczema. It i^ doubtful if any local causes of dermatitis, acting for a 
limited period, could produce a persisting eczema without cooperation 
of other conditions, either internal or external. The large majority 
of all externally operating causes of dermatitis fail to he effective in 
the mass of individuals. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration: they can all be 
referred to either solar light and heat, to contact with foreign bodies 
in various fluid or solid states, to toxic agencies of a widely differing 
nature, to traumatisms in varying degrees, and to the action of para- 
sites. Manx - of these agencies cooperate, some include others, and 
some become effective by aggravating a disease which others have 
engendered, due reader i> referred to the chapters on General Eti- 
ology and Dermatitis for fuller consideration of this subject. It will 
he sufficient to note here that acids, alkalies, antimonial and mercurial 
compounds, mustard, sulphur, castor-oil, capsicum, arnica, turpentine, 
chloroform, ether, alcohol, and a long list of other medicaments are 
capable, when applied to the skin, of producing a dermatitis that, in 
susceptihle individuals, will persist after removal of the cause, and 
may therefore he classed as an eczema. The same statement is true 
of articles manipulated in many of the trades — those, for example, 
handled by the grocer, the baker, the confectioner, the seamstress, the 
ink-manufacturer, the mason, the cook, the gardener, the laundress, 
the painter, the dyer, the printer, the tobacconist, and the chemist. 1 
Then, too, the eczema of the person exposed to severe cold, or to in- 
tense solar light and heat, aided by reflection from water, or even to 
excessive artificial heat, as the fire of a furnace, illustrates the action 
of other causes named. Pressure- and friction-effects are exhibited 
in the inflammatory effects produced by contact with shoes, the edges 
of cuffs, trusses, crutches, and corsets. 

Scratching is a fruitful cause of the persistency of an eczema when 
the latter is well established. The experiments of Torok 2 and Iloma 3 

1 Knowles, Jour. Cut. Dis., 1913, xxxi, p. 11: The External Origin of Eczema, Par- 
ticularly the Occupational Eczemas, as Based on a Study of 4142 Cases. 

2 Archiv, 1902, lxiii, p. 27. 3 Ibid., p. 39. 



ECZEM I 

indicate thai mechanical irritation of the normal skin, even in patienl 
predisposed to the disease, will nol produce a vesicular eczema, though 
in very sensitive skins a dermatitis with an exudate may result, and it' 
the irritation be sufficiently prolonged it may cause ;i lichenoid infil- 
tration. 

Water is capable of exercising an injurious effect upon the skin to 
the extent of producing an eczema when applied externally as a fluid 
in excessively cold or hot temperatures, or in the vapors of Turkish 
and Russian baths, or if it be rendered irritating by saline or other 
constituents. 

External causes of eczema are at times climatic, the disease being 
often worse during the cold seasons. Cold winds and sudden tempera- 
ture changes, especially from warm to cold, will often aggravate and 
prolong an existing eczema. 1 

The external sources of eczematous trouble named above should be 
regarded simply as suggestive illustrations. Every contact with the 
external world sufficiently severe or prolonged to awaken the resent- 
ment of the healthy skin may be followed by the protest of the latter 
in the shape of an eczema; and the same may be true when even the 
most trivial external accidents occur to the sensitive skin of individuals 
especially prone to the disease. 

Among other organisms 2 described as the cause of eczema may be 
mentioned the Morococcus of Unna. 3 More recently, this organism 
is being regarded as identical with the Staphylococcus epidermidis 
albus. Galloway and Eyre 4 describe cocci producing whitish cultures 
found in early and uncomplicated lesions of papulo-vesicular eczema. 
Whitfield 5 describes a peculiar diplococcus, which grew T in the form of 
whitish or yellowish cultures on agar and did not liquefy gelatin, 
isolated from that variety of eczema which manifests itself in the 
form of small, dry disks on the cheeks of young children. 

The probability that some forms of eczema are due to toxins of 
different microorganisms seems to be established by the experiments 
of Bender and Gerlach. 6 In a long series of control experiments, they 
found that inoculation of the normal skin with cultures of staphy- 
lococci produced an impetigo or a simple pyodermia, but when filtrated 

1 Corlctt, Jour. Cut. Dis., 1894, vol. xii, p. 457, and Jour. Amer. Med. Assoc, De- 
cember 20, 1902, p. 1583; Warde, Brit. Jour. Derm., 1903, xv, p. 349; and Corlett and 
Cole, Amer. Jour. Med. Sci., June, 1912, p. 710. 

2 For a full discussion of the parasitic and other causes of eczema consult the Trans- 
actions of the IV International Congress of Dermatology, Paris, 1900 (Compt. rendu, 
XI 11 Congr. Internal, de Med, pp. 9-94, abstr. in Brit. .Jour. Derm., L900, xii, 
p. 326); also papers by Morris, Brit. Jour. Derm., 1898, x, p. 359; Roberts, ibid., 
L899, xi, pp. 7 and 66; Torok, Annales, L898, s. iii, ix, p. 1073, and 1899, s. iii, x, p. 37; 
Sabouraud, ibid., 1899, s. iii, x, p. 305; Leredde, ibid., 1899, s. iii, \, pp. 30 and 138; 
Kromayer, Archiv, 1900, liii, p. 85; Scholtz et Raab, Annales. 1900, s. iv, i. p. 109; \\ hit- 
field, Brit. .Jour. Derm., 1900, xii, p. 400; Schwenter-Trachsler, Monatshefte, 1903, 
xxxvh, p. 233; Engman, American Medicine, L902, iv, p. 769; see also chapters by 
Besnier, La Pratique Dermatologique; and buna, Mracek's Eandbuch. A brief sum- 
mary is to be found in MacLeod's Pathology, p. 3 11. 

:< Monatshefte, ISO!), xxix, p. L06. ' Brit. .Jour. Derm.. L900, \ii, p. 307. 

■ [bid., p. 327. » Monatshefte, 1901, \\\iii. p. l 19. 



204 HYPEREMIAS AND IXFLAMMATIONS 

bouillon cultures of the same organisms, which contained no cocci but 
only their toxins, were employed, the result was a papulo-vesicular 
eczema of ordinary type. The primary vesicles so produced were 
sterile, but later contained staphylococci. On the other hand, Cole, 1 
in a series of well-controlled experiments, failed to corroborate the 
above findings. Bockart 2 believes that in individuals predisposed to 
eczema staphylococci may remain inert in the mouths of follicles until 
some cause from without or within arouses them into activity. They 
then produce toxins which are diffused through the epidermis and 
produce eczema. The lesions so produced are invaded subsequently 
by cocci and other organisms, so that the later changes in eczema are 
due largely to other agencies. Whitfield, 8 Sabouraud 1 and others 
have demonstrated the causal relation of the fungus ordinarily found 
in tinea cruris t" certain cases of eczema of the fingers and toes. The 
causal role played by microorganisms in the infectious eczematoid 
dermatitis is evident. 

Pathology. The pathological changes in eczema are those of 
Inflammation of the skin, varying somewhat with tin* acuteness or 
chronicity of the process, and with the character and career of the 
exudate furnished in each expression of the disease. In most cases 
there is, fir>t, a circumscribed or diffused hyperemia of the affected 
part, followed by dilatation and congestion of the blood-vessels of the 
coriiiin. with perivascular cellular infiltration and exudation of serum, 
producing edema. 

The process probably begins in the papillary layer, from which it 
extends to the epidermis, to the deeper parts of the corium, and, in 
exceptional cases, inward even to the subcutaneous tissue. The 
edematous infiltration may be quite extensive, producing marked 
swelling over considerable areas, or it may be slight and circum- 
scribed. At times it appears only about the hair-follicles, producing 
perifollicular papules. The cell-infiltration about the vessels of the 
corium is formed in part of leukocytes, some of which wander outward 
into the rete, but it is probably composed largely of young connective- 
tissue cells. 

The epithelial changes in eczema vary greatly with the stage, inten- 
sity, and type of the disease. It is not determined definitely whether 
these changes are always dependent upon and follow the conditions 
described above in the corium, or whether they are usually, or even 
rarely, primary in origin. It is probable that they are secondary to the 
vascular changes in the corium, though some observers, including Unna 
and Leloir, believe that in most cases the epithelium is first affected. 
In practically all forms of eczema there is a parenchymatous edema of 
the epithelial cells, especially of the transitional layers, as a result of 
which there is imperfect keratinization (parakeratosis) of the horny 

1 Archiv, 1913, cxiv, Sec. 3, p. 207; abstr. Jour. Cut. Dis., 1913, xxxi, p. 593. 

2 Monatshefte, 1901, xxxiii, p. 421. 

3 Lancet, July 25, 1908, and Brit. Jour. Derm., 1911, xxiii, p. 36. 

4 Annates, June, 1910, p. 289. 



ECZEMA 205 

layers, the cells of which contain some moisture, retain imperfeci 

nuclei, and arc exfoliated in scales. In acute erythematous eczema 
running a brief course the epithelial changes may be limited to this 
parakeratosis, l»nt in in<»>t cases they are followed by vesicle-forma- 
tion in the upper part of the rete. The manner in which vesicles arc 
formed is a matter of dispute. Some observers report that the 6rs1 
vesicles of acute eczema apparently are due to the formation in a Dum- 
ber of contiguous cells of a clear space between the nucleus and the 
protoplasm, which enlarges until then' is left merely a meshwork filled 
with serum. Other writers 1 state that the prickle-cells are forced 
apart mechanically by the intercellular edema forming small space-. 
The vesicles so produced may he unilocular, hut often are subdivided 
by remnants of prickle-cells into several chambers. The edema may 
cause a separation of practically all the cells, producing Tuna's "spongy 
metamorphosis" of the epidermis. The intracellular edema descrihed 
above follows. As a result of compression, the prickle-cells about the 
vesicle may assume a spindle-shape. The vesicles, though usually 
superficially situated, may he found in any part of the rete. MacLeod 
states that they form in the region of least resistance, which in eczema 
is commonly the superficial portion of the prickle-cell layer, but when 
the edema appears with unusual rapidity the greatest strain is put on 
the cells nearest the basal layer, where the vesicles then are formed. 
Again, the edema may diminish somewhat, permitting the cells be- 
neath the vesicles to become cornified, thus locating the vesicle en- 
tirely within the stratum corneum. The vesicles contain, first, serum 
with fibrin; later, leukocytes in varying numbers, more or less degener- 
ated epithelial cells, and nuclei. As a result of more active degenera- 
tion of cells, or of secondary infection, the vesicles become pustules, 
the contents of which dry on the surface, forming thick crusts. In 
very acute cases, with an abundant exudate, the horny layer may he 
raised from the rete to form vesicles or bullae. According to Unna, 
vesicles in the later stages of eczema [ire due solely to an intercellular 
edema. 

In eczema rubrum the horny layer is raised from the rete and 
destroyed without true vesicle-formation. The rete is thus exposed 
directly to the air, or is partly covered by an amorphous coating of 
dried serum and degenerated cells. 

In the later stages of eczema there is more or less hypertrophy of 
the rete I Tuna's acanthosis), with corresponding enlargement of the 
papillae, forming papules and elevated, thickened areas. In chronic 
cases the cell-infiltration and proliferation in the cerium become very 
conspicuous, producing the thickening of the skin so characteristic of 
patches of chronic eczema. In these cases the papilla? are larger than 
normal, and the vessels of the coriuni are dilated and surrounded by 
connective-tissue cells. The process may extend to the subcutaneous 
fatty layer, which then loses much of its fat, and becomes dense and 

1 MacLeod, Pathology, i>. 101. 



200 HYPEREMIAS AND INFLAMMATIONS 

attached to the skin. Hypertrophy of connective tissue and lymphatic 
obstruction, with elephantiasic changes, may follow. In these cases 
the sebaceous and coil-glands and the hair-follicles may be partially 
or entirely destroyed by undergoing degeneration and atrophy. 

According to Ehrmann and Kick, 1 three conditions, viz., acanthosis, 
spongiosis, and parakeratosis, are always to be found in eczema, the 
degree of development of each varying with the type of the disease. 

The fluid exuded in eczema, in vesiculation or in a free discharge 
from the surface, is always characteristic. Though in the earliest 
vesicles it is a blood-serum, it soon becomes a yellowish-white, sticky 
and syrupy liquid, feebly alkaline in reaction and deposits albumin in 
abundance when treated with heat and nitric acid. Exposed to the 
air, it desiccates in light-yellowish to brownish, friable crusts, resem- 
bling honey or gum. 

Increase in the pigment-particles distributed to the epithelia of the 
rete is characteristic of the chronic forms of eczema, and more espe- 
cially of those in which the circulation is somewhat impeded by the 
influence of gravity, as, for example, in the lower extremities. 

Diagnosis. Though of a do/en consecutive cases of eczema no 
two may look alike, yet they all have some characteristics in common 
and the diagnosis is usually attended with little difficulty. Eczema 
in its manifestations is such a protean disease and is, moreover, of such 
frequent occurrence, that it i> necessary to establish a differential diag- 
nosis between it and a large number of other cutaneous disorders. 
The more important of these are named below in alphabetical order 
for convenience of reference, the distinctive peculiarities of each being 
briefly appended. In making a diagnosis it must be remembered that 
eczema may coexist with any other disease of the skin, and that it 
very frequently thus complicates such cutaneous disorders as sebor- 
rhea, psoriasis, and scabies. 

Acne. Acne occurs chiefly on the face, the neck, and the back of 
the trunk, and its pustular forms may be mistaken for eczema of the 
same localities; but pustular acne is usually accompanied by a deeper- 
seated infiltration than the similar lesions of eczema, and this infil- 
tration is also generally limited to the sebaceous glands or the peri- 
glandular tissue. In eczema the itching is often severe, while in acne 
the subjective sensations are those of heat or burning. Comedones 
intermingled with the pustules of acne will aid in distinguishing the 
two. 

Erythematous eczema of the face is to be distinguished from acne 
rosacea by the more generalized infiltration of the former, its pro- 
duction of itching, and its greater diffusion over the face; while acne 
rosacea is limited more often to the cheeks, nose, and brow, and to 
the regions adjacent to these parts. The patch of erythematous eczema 
is hot, that of acne rosacea is cold, to the touch. The former is seen 
in infancy, the latter is rare in that period of life. Acne rosacea in 

1 Kompendium der Speziellen Histopathologie der Haut, Wien, 1906. 



ECZEMA 207 

many cases is distinguished readily by the development of vi ible 
blood-vessels in the skin of the cheeks or the nasal region. La tl; . 
in erythematous eczema the eyelids may suffer, while in acne ro 
this is the exception. In severe forms of acne the subepidermie pus- 
formation and the resulting sear will prove significant. 

Dermatitis. Dermatitis of artificial origin is to be distinguished 
from idiopathic eczema rather by its history than by special differ- 
ences in the appearance or evolution of the lesions. In many cases I he 
two affections are indistinguishable. A history of traumatism or of 
the external application of irritant or toxic articles will often serve 
to distinguish the two. When the dermatitis has been produced by 
an externally applied irritant, the resulting inflammation of the skin 
will often exactly outline the area of contact. Dermatitis of artificial 
production is usually sudden in its ouset, the date of which will nearly 
correspond with the time of operation of an exciting cause. The 
subsidence of the symptoms after the withdrawal of the cause will 
also point to the nature of the affection. Eczema is also much more 
capricious in its distribution and career than dermatitis. 

Erysipelas. — Erysipelas is generally accompanied by febrile symp- 
toms; in some cases bulla? appear. The affected surface is reddened, 
much more swollen than in eczema, owing to the involvement of deeper 
tissues, and it exhibits besides a characteristic shining appearance, 
which is always absent in erythematous eczema. The line of demar- 
cation between the affected and unaffected portions of the skin is 
usually distinctly defined in erysipelas, ill-defined in eczema, and in 
the former disease is markedly tender. Erysipelas is an exceedingly 
acute affection and spreads from one point to another with a rapidity 
that is never noticed in eczema; the latter disease, moreover, usually 
exhibits under a lens its minute papules or vesicles. In eczema, also, 
when occurring upon the face in the erythematous form, the scalp i> 
usually spared, while erysipelas tends to invade the scalp and the 
regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of ery- 
thema which are due to hyperemia only by the presence of an inflam- 
matory process. The erythema simplex which advances to exudation 
at once transgresses the artificial line of distinction between the purely 
congestive and the purely exudative disorders. It must therefore he 
remembered that many eczemas begin as erythemata, and that 
clinically the latter may represent but a stage in the morbid process. 
The discharge in erythema intertrigo results from imprisoned or from 
chemically altered sweat, and will not stiffen linen, as does the serons 
exudation of vesicular eczema, for example. Erythema multiforme, an 
affection really on the border-line between the two pathological classes 
here sought to be distinguished, will be recognized by the absence of 
severe itching and by the recurrence of the disorder at certain special 
seasons of the year; while erythema papillosum, erythema tuberosum, 
and erythema nodosum display solid elevations of the skin-surface 
much exceeding in size the minute lesions of papular eczema. 



208 HYPEREMIAS AND INFLAMMATIONS 

Herpes. — Eczema, in the minds of many, is so associated with the 
occurrence of a vesicle that other vesicular disorders are likely to be 
confounded with it. But in herpes febrilis the vesicles usually are 
grouped about the mucous outlets of the body, and when actually 
under observation are seen to exceed in size the minute and transitory 
lesions of vesicular eczema. In herpes zoster, with the limitation of 
the eruption to the course of a nerve on one side of the body, and the 
production of grouped vesicles of a larger size and more persistent 
type, there is commonly a history of precedent or coincident neuralgic 
pain. The subjective sensation in the skin is a decided burning rather 
than itching, and there is a possibility of the subsequent production 
of scars. 

Impetigo. In these forms of disease the pustular lesions are usually 
isolated, do not spring from an infiltrated surface on which other lesions 
may be visible, and are unaccompanied by the intense itching which is 
characteristic of eczema. The pustules, moreover, are larger and the 
resulting crusts, ;i> a rule, are bulkier and darker colored than those in 
eczema. Again, in pustular eczema the cutaneous affection usually 
occurs in one <>r more patches, while in impetigo a dozen or more iso- 
lated pustules may be irregularly scattered over the entire surface of 
the body. In impetigo there may be a history of extension of the 
disease from one member of a family to another. 

Lichen Planus. Papular eczema may be confounded with lichen 
planus, but in the latter disease the typical papule has an irregular 
or polygonal base; a Hat or umbilicated apex, which is covered with a 
thin, closely adherent, varnished-looking scale; and a violaceous or 
dull-crimson hue. The papules of eczema have round or oval bases, 
acuminate or rounded summits, and are brighter red in color. They 
also form more rapidly and undergo change of type more frequently 
than the more persistent papules of lichen planus. The patches of 
lichen planus are more sharply defined than those of eczema and are 
usually angular or linear in outline. The lesions of lichen planus on 
disappearing leave a characteristic brown or sej ia-tinted pigmentation. 

Lupus Erythematosus. — Lupus erythematosus greatly resembles cer- 
tain forms of squamous eczema. The great chronicity of lupus; the 
firm attachment of the scales; the symmetrical distribution of many 
patches upon the face; the association of some forms of the disease 
with the sebaceous glands; the definite border of each involved area; 
and, above all, the discovery of a cicatrix left by the morbid processes, 
will sufficiently distinguish the disorder. In eczema there are usually 
itching, often vesiculation, more rapid extension of the borders of a 
single patch, and scales much more loosely attached than in erythem- 
atous lupus. The scales of eczema are never provided, as in lupus 
erythematous, with stalactiform plugs on the inferior surface. 

Lupus Vulgaris. — Lupus vulgaris is readily distinguished from eczema 
by its more chronic career, by its larger papules and tubercles of dark 
reddish-brown hue, and by every one of its destructive processes, none 
of which is ever recognized in eczema. 



ECZEMA 209 

Granuloma Fungoides. Granuloma fungoides, in its earlie I 
may be indistinguishable clinically from some forms of localized or 
even generalized eczema. As a rule, however, the early erythematous 
and eczematoid lesions of mycosis fungoides can be recognized by their 
characteristic gyrate outlines, assuming, as they do, the shape of a 
kidney, horseshoe, half-moon, and other fantastic more or less circinate, 
forms. These lesions may change frequently in form and location. 
or may disappear spontaneously, to return in the same or in new sites. 
They ditl'er further from eczema in being located on any or every part 
of the body, independently of external influences, and in failing to 
respond to treatment during months or years. After the formation of 
characteristic thickened and elevated plaques, the diagnosis is not 
difficult. 

Pediculosis. — As eczema is often induced by lice upon the head, the 
pubes, or the clothing, it is always necessary to exclude the operation 
of such causes for both diagnostic and therapeutic purposes. Eczema 
limited to the pubic region or to the pubic and axillary regions should 
suggest careful examination of the skin and the hairs for the discovery 
of the crab-louse. As for the Pediculus corporis, it should be the rule 
of the physician (whatever the social position or refinement of his 
patient) to search in a suspected case for evidence of the parasite upon 
the under surface of the clothing worn next the skin, at the instant of 
its removal and while the patient supposes him to be busied with the 
inspection of the cutaneous lesions. The excoriations produced by 
scratching wounds inflicted by body-lice are usually out of all propor- 
tion to the amount of skin-disease present; and this excoriation is the 
most significant of all symptoms next to the discovery of the corpus 
delicti. Head-lice may precede or may follow eczema of the seal}), 
but either they or their ova (nits), clinging in numbers to the hairs, will 
be visible to him who looks carefully for them. 

Pemphigus and Pityriasis Rubra. — The large, isolated bulhe of pem- 
phigus vulgaris are never seen in eczema. In pemphigus foliaceus 
the lesions arc succeeded by the formation of pastry-like crusts, serous 
exudation, considerable soreness, and the eventual production of an 
extensive and often fatal exfoliative dermatitis. Marasmus gradually, 
or in sonic cases rapidly, ensues, while, as a rule, itching and infiltra- 
tion arc not present. The disease known as pityriasis rubra is equally 
rare and fatal, and, though unattended by the production of bulla?, 
is characterized by an abundant epidermic exfoliation; itching and 
infiltration being either entirely wanting or insignificant in comparison 
with the other symptoms present. The scales, too, are fine and branny, 
or larger, papery, and thin; there arc no vcsicnlation and moisture, and 
little, if any, infiltration of the skin. The integument is, moreover, 
of a uniformly reddish hue. Both pemphigus foliaccns and pit\ ria>i> 
rubra are particularly liable to be complicated with chills or with 
uncontrollable diarrhea. Without question, many of the reported 
cases oi so-called pityriasis rubra are instances of squamous eczema 
or of simple exfoliative dermatitis. Here the limitation of the disease 
14 



210 HYPEREMIAS AND INFLAMMATIONS 

to one or more patches upon the body, the severe itching, and the 
distinct infiltration of the patch point to the eczematous character 
of the disease. Observation of such patients will finally show, in 
many cases, that there is occasional weeping from the surface. 

Pityriasis Rubra Pilaris often resembles in a high degree, and it 
may indeed be confused with, the squamous forms of eczema. In 
general, there are not found in eczema characteristic lichenoid papules 
formed about the hair-follicles, with their hyperkeratinized cap sheath- 
ing the follicular orifice. Nor is the selection of the extremities, and 
especially the dorsal aspect of the fingers, characteristic of eczema. 
In eczema there are usually distind marks of scratching, that may 
wholly be wanting in pityriasis rubra pilaris; and the latter has in 
most eases a more chronic course. 

Prurigo. In the prurigo of Ilebra, a disease exceedingly rare in 
America, there are infiltration, intense itching, and numerous minute 
and larger papules. But this disease usually occurs within a year or 
two after birth and lasts for a lifetime, extending generally over the 
greater part of the body, sparing only the palms and soles (which 
eczema does not), and being accompanied by inguinal adenopathy. 

Pruritus. In pruritus, often confounded with prurigo, there is itch- 
ing without lesion of the skin save that induced by scratching to relieve 
the sensation. Hence* pruritus without scratching will not reveal a 
cutaneous disease, while pruritus with scratching will exhibit either 
excoriations or a dermatitis induced by the attacks made upon the 
skin. The former condition, however, is rarely noted. The distinc- 
tion will be clear when it is remembered, first, that pruritus is usually 
of a paroxysmal character, being worse regularly at certain hours or 
seasons; second, that pruritus not originating in a cutaneous lesion, 
but indirectly producing the latter by the medium of the finger-nails, 
never exhibits as much cutaneous excoriation as the skin attacked with 
eczema. The impressive features here are always the disproportion 
between the complaint of the patient and the visible symptoms, and 
the vast preponderance of all lesions in those regions of the body most 
accessible to the hands, such as the anterior faces of the limbs, the 
genital region, and the lower abdomen. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. Vari- 
ations in type from one to the other furnish many obscure cases. The 
following are the chief diagnostic points in psoriasis: sharp definition 
of contour of patch; abundance and lustrous hue of the scales; absence 
of moisture; vascularity of tissue beneath the scales; sites of election 
on posterior aspect of the trunk and extensor surfaces of limbs; chron- 
icity in course; uniformity of lesions; and usually absence of itching. 
In eczema there are an ill-defined contour; usually scanty scales, not 
having a nacreous hue; a preference for the flexor surfaces of the ex- 
tremities, though the disease may occur in any portion of the body; 
generally, at some period in its course, a history of moisture; poly- 
morphism as regards lesions; and a marked intensity of subjective 
sensations. Upon the scalp psoriasis is prone to extend beyond the 



ECZEMA 21 I 

hairy border in a fillet stretching across the upper portion of the fore- 
head, thence irregularly down in front of the ears; while in eczema of the 

face, when the scalp is also invaded, the disease extends to the lower 
forehead, the lips, nose, cheeks, or chin, regions which are relatively 
spared by psoriasis. Finally, the two diseases, in doubtful cases, will 
generally be distinguished by carefully searching the entire surface of 

the body, upon sonic part of which in psoriasis there will usually be 
discovered a typical patch. 

Scabies. Scabies is really an artificial dermatitis induced by the 
incursions of the Acarus scabiei, and its lesions are thus very similar 
to those of eczema. In scabies, however, the itching is intense, and the 
recently formed papules, vesicles, and pustules are more distinct and 
isolated than in eczema. The discovery of the parasite, especially if 
there be a history of contagion, and the localization of the disease in 
its sites of preference, will at once determine the diagnosis. Scabies 
never attacks the scalp. Its sites of preference are in both sexes the 
fingers, hands, wrists, and axilla?; in women the breast and the nipple; 
in men the penis; and in children the buttocks. The presence of the 
acarian furrow, if the disease has existed for some time, and the appear- 
ance of minute blackish dots or points upon or about the lesions, usually 
suffice to establish the nature of the disease. 

Sycosis. — Both the hyphogenous and the coccogenous forms of sycosis 
are limited to the region of the beard, while eczema of the hairy por- 
tions of the face will usually be found to affect other parts. In eczema 
the itching is severe, the exudation spreads beyond the limits of the 
beard, and the discharge is characteristic; while in both forms of sycosis 
there is less oozing and the subjective symptoms are trivial. The dis- 
covery of the parasite in the root of the shaft of the hair will at once 
distinguish the hyphogenous forms of the disease. In coccogenous 
sycosis each pustule is perforated by a hair. Eczema limited to the 
region of the beard is even rarer than the two varieties of sycosis. The 
circumscribed indurations and tuberculations of the affection pro- 
duced by the Trichophytons, as w T ell as the loosening of the hairs in 
their follicles, constitute further distinctive differences. 

Syphilis. — Several syphilitic eruptions resemble certain forms of 
eczema. In the eruptions due to syphilis, however, there is usually a 
history of infection; of involvement of the glands and mucous surface's; 
of ulceration and cicatrices in advanced periods; and, especially in the 
case of infants with an eczema-like eruption, a history of snuffles. 
The intense itching of eczema is characteristic of no one of the 
syphilides, and the latter are remarkable for their tendency to occur 
with a circular or partially circular outline, and to be covered with 
bulky, malodorous crusts. A point worthy of note is that, compared 
with chronic eczematous affections, a syphilitic eruption limited for an 
equal period of time to one 1 locality will often ulcerate or exhibit evi- 
dences of repair by scar-tissue, no such results occurring in eczema. 

Syphilis of the palms and soles exhibits very distinct outlines in the 
usually circular, circumscribed, and deeply infiltrated patches present, 



212 HYPEREMIAS AND INFLAMMATIONS 

which are often symmetrical in development, or are at least situated 
on both sides of the body, even if more fully developed upon one limb. 
Syphilitic pustules upon the scalp usually rise above superficial but 
well-defined ulcers. Syphilitic eruptions encircling the mouth in 
children arc less angry-looking and formidable than those of severe 
eczema of the same region, being often made np of flattened papules, 
moist or scaling, grouped in circles about the lips, with mucous patches 
at the angles. 

Trichophytosis Corporis. In ringworm there should be a history of 
contagion, microscopical discovery of the vegetable parasite, distinct 
contour of all separate patches, and absence of marked subjective sen- 
sations and of discharge. In ringworm of the scalp the hairs, loosened 
in their follicles, arc usually either brittle or arc 1 actually broken at a 
short distance from the scalp; the scales arc line, dirty-white, and not 
torn from the surface by the finger-nails. In eczema the hairs are 
unaffected, and their extraction is productive of pain. In ringworm 
of the body the patches are distinctly circular, arc more scaly or papular 
at periphery than centre, and, moreover, yield with promptness to the 
action of a parasiticide. Occurring about the thighs and ano-genital 
region, the disease may be complicated by eczema, but the character- 
istic "festooning" of the advancing border of the patch downward 
along the thigh, or upward over the pnbes, will suggest a microscopical 
examination of the scales scraped from the surface. 

Tinea Favosa. The large, friable, dirty crusts of an old and neglected 
favus of the scalp might be mistaken for the crusts of eczema of the 
same part; but here the exudation is slight, and there is little scratching, 
as in eczema, hence no history of discharge. The odor, moreover, is 
peculiar. In case of uncertainty, a careful search will reveal a few 
characteristic cup-shaped and yellow crusts, or the microscope will 
demonstrate the parasitic nature of the disorder. 

Tinea Versicolor.— In this disease, also, the microscope will reveal, 
beneath the epidermal plates, the spores and filaments of the fungus 
which produces the ailment. From eczema the disease is easily dis- 
tinguished by the absence of infiltration and of any history of inflam- 
mation; by the very slight subjective sensation it produces; and by its 
peculiar fawn- to chocolate-colored, slightly yellowish patches, which 
are covered with superficial furfuraceous scales, are limited to the 
covered parts of the body and often to the anterior surface of the 
trunk, and are readily removed by the action of a parasiticide. 

Urticaria. — In papular forms of this disease there may be a resem- 
blance to eczema. This resemblance is more marked in children, as 
here the two diseases may be intermingled. Characteristic wheals 
often occur by the side of eczematous patches, but, as a rule, urticarial 
lesions are less grouped, more generally disseminated, more evanescent, 
and much less scratched. 

Treatment. — The treatment of eczema usually presents a compli- 
cated problem. The causes of the disease are numerous, frequently 
obscure, and when discovered are often difficult to remove. Eczema 



ECZEM \ 



> i ■■ 



shows little tendency to spontaneous recovery, but tends rather to 
persist, to spread to contiguous or distant parts <>f the body, and to 
recur. Although many cases of the disease respond well to local treat- 
ment alone, if the affected surface can be given absolute rest and kepi 
constantly covered with the desired dressing, such ideal treatment 
can rarely be carried out except with hospital patients. Moreover, in 
many cases of eczema the general health of the patient must be im- 
proved before local treatment can be effective. The nutrition and 
functional activity of the skin depend largely upon the condition of the 
general system, for the skin is but one of many organs in a complex 
organism. It follows, also, that every serious disease of the skin must 
interfere more or less with the general health. The fear that too rapid 
a cure of eczema may result in disease of deeper-seated organs is base- 
less. The sudden improvement or disappearance of an acute eczema 
coincidently with the development of a pneumonia or other grave dis- 
order may be explained by the rapid withdrawal of a large amount 
of blood from the skin-surface to the newly-congested organ. The 
improvement in the eczema is thus a result and not a cause of the 
deeper-seated disease. 

The treatment of eczema requires both local and constitutional 
management. 

Constitutional Treatment. — In many cases internal treatment may 
be wholly ignored, and eczema be successfully controlled by local 
measures alone, even though there be coincident systemic disease. 
Often, however, the eczema is an external expression or result of other 
pathological conditions, which must be removed before the eczema 
can be permanently cured. These systemic disorders vary widely, 
ranging through the whole field of internal medicine and hygiene. 
In these pages a few suggestions only can be given regarding the inter- 
nal treatment of eczema, the major portion of such treatment depend- 
ing entirely on individual findings. It is often necessary not only to 
relieve disease of other organs, but also to study the patient's tempera- 
ment, habits of eating, drinking, bathing, and sleeping, before an 
obscure cause of stubborn eczema can be found and removed. 

Diet. — No absolute rule can belaid down regarding the diet in eczema, 
Each individual should be given the quantity and quality of food that 
will best nourish his body without interfering with digestion and 
elimination. The anemic, strumous, and poorly nourished subject 
should be given sufficient fresh beef, mutton, eggs, milk, cream, vege- 
tables, and other nourishing foods. Cod-liver oil, butter, and other 
fats, when easily digested, are of special value, as also are the various 
malt-preparations, particularly when digestion of the carbohydrates is 
at fault. In the plethoric, the overfed, the gouty, and in those suf- 
fering from faulty digestion and elimination, a diet restricted to the 
lowest point consistent with the health of the individual is often of the 
greatest importance. In these cases excellent results are obtained by 
limiting the patient to a diet of bread and milk, or of milk alone, or 
of milk and seltzer-water, for several weeks. In general, the diet 



214 HYPEREMIAS AND INFLAMMATIONS 

allowed the eczematous patient should he limited to the most digestible 
articles of food and should exclude those (a list of which is given in 
the chapter on Urticaria) capable of exciting cutaneous irritation. 
Cooked vegetables, fruit, and a small quantity of fresh meat may he 
permitted; hut starchy articles in excess, hot breads and cakes, pastry, 
confectionery, cheese, pickles and pickled meats, the heavier vege- 
tables, shell-fish, salted fish and meats, and pork and veal should he 
avoided. Coffee, tea, and cocoa are in the doubtful list, as they are 
positively injurious to some patients and apparently without effect on 
others. Water, as free from mineral constituents as procurable, may 
he taken freely between meals. Alcohol in every form is contra- 
indicated save in conditions of debility, or in case of its previous 
habitual use in moderation by persons of advanced years. In gouty 
patients the dietary should he of the strictest appropriate to that 
condition, and in diabetic eczema the regimen proper in glycosuria is 
observed with great benefit in most cases. 

Internal Medication. There an 1 no specifics for eczema. Such 
remedies only should he given as are indicated by the general con- 
dition of the Individual. The chief object of the constitutional, and 
also of the local, treatment of eczema is to remove all sources of 
irritation of the inflamed skin. 

An attempt to relieve itching by the use of anodynes internally is 
rarely necessary, and usually aggravates the disorder. Opium and 
its preparations increase the itching, though in full doses they relieve 
temporarily. With some patients, and especially children, full doses 
of quinin may relieve itching. Aspirin is of value as an antipruritic. 
Less frequently, full doses of calcium chlorid, largely diluted with 
water, may serve the same purpose. In an emergency, chloral, phe- 
nacetin, sulphonal, or even the hromids, may he given, hut, like 
opium, they all are liable to aggravate the itching after a first anodyne 
effect has passed. 

In the management of acute eczema cooling draughts are useful; 
and in all cases occurring in patients who are plethoric or constipated, 
or who suffer from other symptoms of imperfect excretion, aperients 
and cathartics are needed. Often a brisk mercurial purgative in the 
form of blue mass or the compound cathartic pill may he ordered at 
the outset. Five grains (0.33) of blue mass or one to three grains 
(0.06-0.2) of calomel may be given each night, followed by a saline 
laxative in the morning, for several successive days, or once every 
third or fourth day. A tenth of a grain (0.006) of calomel combined 
with sodium bicarbonate may be given every hour for a day or two, 
and then, three or four times daily for two w r eeks or longer, if at the 
same time salines are used to keep the bowels freely open. The rhu- 
barb-and-soda mixture answers w T ell in some cases. _ Podophyllin, or 
the familiar combination, nux vomica and aloes, may be substituted 
for these articles. The saline cathartics, whether employed in medici- 
nal formulae or in natural mineral waters, such as the Hathorn, Karls- 
bad, Hunyadi Janos, or Friedrichshall, are exceedingly useful in the 



ECZEMA 215 

management of most, cases. The following Isa valuable combination, 
often advised for cases in which l><>th iron and magnesium sulphate 

are indicated: 



U Magnes. sulphat ., 
Acid. Biilphur. dil., 
Ferri sulph., 
Sodii chlorid., 
Cardamom, t incl . com] 
Aq. deet., 


>., 


nd. 


5ij; 
f5ij; 

3j; 

IT)iv 
Oss; 






CO 
8 

4 
15 

210 


CO 
M. 


Filtra. 

Sig. — A tablespoonful before 


bi- 


eakfast in a 1 


umblerfu] 


of 


cool or 


of hot water 



An excellent remedy for some cases is from 15 to 20 drops of a fluid 
containing 2 parts of the fluid extract of cascara sagrada to 1 part each 
of glycerin and tincture of aloes, the dose to be taken at bedtime or 
before breakfast in a small glassful of water. A full dose of castor-oil 
on retiring is an excellent remedy in many neurotic cases, and may be 
continued for weeks if needed. 

In some cases of renal derangement the alkaline diuretics are indi- 
cated, such as potassium acetate, carbonate, or citrate, administered 
with nitre, squills, caffein, or lithium benzoate in from 3 to 5 grain 
(0.2-0.33) doses before meals, and in gouty cases colchicum, Vichy 
water, etc. Distilled or other pure water, or in suitable cases the alka- 
line spring-waters, taken in large quantities before meals and between 
meals, are very valuable as diuretics and as a means of encouraging 
elimination. In patients suffering from hyperchlorhydria, liquor 
potassse, sodium bicarbonate, ammonium carbonate, or milk of 
magnesia may be required. Salol and allied drugs are often of value. 

Aloes and iron, or aloes and ergot, are indicated in special eases. 
Where diuretics and alkalies are both indicated, the following formula 
is often of service : 

1$ — Magnes. sulphat., gss; 15 

4 
2 
2 
180 M. 

Sig. — Two tablespoonfuls in a wineglassful of water every three or four 
hours. 

Cod-liver oil is indicated in all eases of struma and tuberculosis; 
calcium phosphate in bronchitis; iron in anemia and chlorosis; strych- 
nin, hypophosphites, and other nerve-tonics in neurotic cases. Anti- 
mony in small doses as an alterative and nerve-tonic or in large doses 
to reduce vascular pressure is often of value. 

In fleshy children affected with eczema calomel internally is a valu- 
able remedy. From \ grain to 2 grains (0.03-0.133), with 2 to 3 (0.13 
0.2) of rhubarb, rubbed up with 5 grains (0.33) of calcined magnesia, 
may be given once in a day to an infant; or .} {) of a grain (0.003) of 
calomel, rubbed up with sugar of milk, may be given three times 
daily for ten or twelve days. Small doses of the unspiced syrup of 
rhubarb, with or without magnesia, may be required for the consti- 
pation of infants, or from 1 to 3 drachms (4. 12.) each of powdered 



Magnes. sulphat., 


gss; 


Magnes. carbonat., 


5j; 


Colchici tinct., 


f3ss; 


Month, pip. ol., 


miij; 


Aq. dest., 


fovj; 



210 HYPEREMIAS AND INFLAMMATIONS 

rhubarb and sodium bicarbonate in 4 ounces (120.) of peppermint- 
water, of which a teaspoonful may be administered two or three times 
or oftener daily. Quinin, strychnin, syrup of ferrous iodid, and 
wine of iron may also be used with advantage when indicated in these 
little patient-. 

Beside those enumerated above may be named the following articles, 
which, after internal administration, have been reported as efficient in 
the hands of various authorities: calx snlphnrata, viola tricolor, sodium 
hyposulphite, ichthyol, chrysarobin, tar, phenol, sulphur, pilocarpin, 
and turpentine. Arsenic, which has been so largely employed by 
the genera] practitioner in eczema and in other disorders of the 
skin, is ;in uncertain remedy in all cutaneous diseases; it is equally 
uncertain in eczema, and has unquestionably aggravated as many 
cases ;i- it has relieved. It> value in some chronic papular and sum- 
mons forms of the disease is undoubted, and in small doses as a nerve- 
tonic it i^ often of value, but it should never be given in acute cases or 
where there is any digestive disturbance. 

Sunlight, fresh ;iir. suitable clothing, and due rigime as to pleasure 
and business, must be, for many patients, controlled by the physician. 
These agencies do not cure eczema; but they do much to aid in its 
management; thej may do more, if neglected, to permit its aggrava- 
tion, ('rocker advocates counter-irritation over the spine — over the 
nape of the neck for eczema- of the upper segment of the body; over 
the dorso-lumbar vertebrae f or the lower parts. Jackson has used the 
ice-bag with advantage in the same way. Counter-irritation of the 
corresponding part of the lateral half of the body for the relief of an 
eczematous patch of long standing limited strictly to the other side 
may also be employed in rare cases. 

Local Treatment. — Local treatment is of value in all cases of eczema, 
is usually imperative, and often is the only treatment necessary. The 
remedies recommended for external application in the various forms 
and phases of eczema are so numerous and varied that barely to men- 
tion all would require many pages; and not even the expert can be 
sufficiently familiar with them all to use each intelligently. A com- 
paratively small number of remedies skillfully handled will suffice in 
all but rare cases. It often happens that in a given type of the dis- 
ease a treatment which one physician uses with brilliant success fails 
utterly to serve a fellow-practitioner who is equally skillful, but who 
is less familiar with this particular method. One of the most common 
errors in the local treatment of eczema lies in the frequency with which, 
in a difficult case, a succession of new medicaments is tried instead 
of studying more carefully the details of application of familiar reme- 
dies. It must not be forgotten that each individual skin, like its pos- 
sessor, has its idiosyncrasies. A remedy that in a given type of the 
disease will commonly give prompt relief may in others prove of no 
benefit and even aggravate the condition. An idiosyncrasy may exist 
forbidding the use of particular drugs, such as phenol, glycerin, 
resorcin, etc., or it may prevent the employment of certain classes of 



ECZEMA 21 i 

applications, as, for example, ointment g, powders, lotion-, etc. The 
choice of remedies must further be influenced iii eadi case by a con- 
sideration of the type or phase, severity, and duration of the disea 
the region and extent of surface involved; and of the age, occupation, 
and climatic and other surroundings of the patient. 

The genera] objects and principles of treatment in eczema may con- 
veniently be grouped under the following heads: (1) exclusion of all 
sources of irritation to the skin; (2) relief from itching, burning, and 
other morbid sensations; (3) antiseptic dressing; (4) reduction of local 
congestion in acute, and stimulation of circulation in chronic, cases; 
(5) repair of the horny layer in acute, and destruction of the thickened 
and abnormally keratinized horny layer in chronic, forms of the disease. 

1. Exclusion of All Sources of Irritation. — This is one of the most 
important, the most varied, and often the most difficult and complex 
problems. Frequently, a simple protective dressing is all that is re- 
quired; more commonly, the object is not so readily attained. Irri- 
tation of the skin due to its malnutrition or to conditions of ill health 
must be relieved in accordance with the principles of internal medicine, 
as has been indicated in discussing the internal treatment of eczema. 

The exclusion of all sources of irritation necessitates, secondly, the 
avoidance of all injurious external contacts. Complete rest is advis- 
able when feasible. The inflamed skin, like an inflamed joint, recovers 
much more rapidly when put at complete rest than is possible under 
other circumstances. 

Next is involved the exclusion of all topical irritants (in the hands of 
either physician or patient) designed to relieve the disorder, but having 
a precisely opposite effect. 

Lastly, the exclusion of all sources of irritation necessitates protect- 
ing the involved surface from the excoriations and other traumatisms 
produced by scratching, rubbing, and excessive washing of the eczem- 
atous skin, and from exposure of the inflamed surface to the air. 
The various applications and protective dressings here serve their pur- 
pose, but in the case of adults some restraint to prevent rubbing and 
scratching is also necessary; in the case of infants this restraint may 
need to be enforced. Fixed dressings are often of great value in immo- 
bilizing a part, or in preventing friction, bruising, or other injury to the 
inflamed surface. A light elbow-splint to prevent flexion of the joint 
often is of service in keeping the fingers from the face. Most patients 
have to be repeatedly and forcibly impressed with the fact that a few 
minutes of scratching or rubbing, or one untimely washing of the in- 
flamed surface, or its unnecessary exposure to the air, may undo all 
that has been gained in several days of patient and successful treatment. 

2. Relief of Itching. The itching, burning, and other sensations 
which accompany eczema are usually largely or entirely allayed by 
the complete protection of the skin from irritation. Antipruritics are. 
however, frequently desirable and necessary. Among the best are 
phenol, hydrocyanic acid, camphor, menthol, and salicylic acid, 
each in the strength of 0.5 to 2 per cent, (rarely stronger), in lotions. 



218 HYPEREMIAS AND INFLAMMATIONS 

ointments, jellies, pastes, etc. Saturated solutions of boric acid, or 
the lead-and-opium wash, answer in many acute cases. If a remedy 
docs not relieve the itching, it should be changed for one that will, 
unless the fault lies in the method of application. The most common 
error in the use of local remedies is found in the five- and ten-minute, or 
longer, intervals during which the skin is not protected, either as a 
matter of convenience or with a view to its appearance or as a result 
of carelessness in removing and reapplying the dressings. Exposure 
of an acutely inflamed surface to the air for a few seconds only may be 
sufficient to arouse a violent attack of itching or burning. The relief 
of itching by the use of drugs internally is considered under the head 
of internal medication. 

3. Antiseptic Dressing. — It i> not known to what extent eczema 
may be due to. or may be modified by, the various microorganisms 
that come in contact with the skin, but severe cases are undoubtedly 
complicated and prolonged by the action of such bacteria, and it is 
well in every case, when possible, to prevent their activity. Simple 
protection does much to accomplish this end, while, fortunately, most 
of the remedies wsvd as antipruritics are also more or less parasiticidal. 
In certain form- of the disease, such as seborrheic dermatitis, sulphur, 
resorcin, and other parasiticides are necessary. 

4. Relief of Local Congestion. This is accomplished by position, 
compression, internal treatment, and largely by the removal of exter- 
nal irritation. Occasionally, a direct astringent action may be ob- 
tained by the use of lead-water, lime-water, or by some of the rapidly 
drying jellies or glyccrogelatin preparations. In chronic eczema pas- 
sive congestioE is removed by means of stimnlating washes, soaps, 
ointments, etc. 

5. Repair of the Epidermis. — If the preceding indications are ful- 
filled, repair takes place naturally. It may be aided and hastened 
somewhat in suitable cases by the use of very mildly stimulating reme- 
dies, such as weak preparations of sulphur, resorcin, ichthyol, thiol, 
tar, etc. In chronic cases with much thickening of the epidermis, 
the abnormally and imperfectly keratinized horny layer must be de- 
stroyed and removed before the process of repair can begin. For this 
purpose salicylic acid in ointment is especially valuable. Other 
remedies used for the purpose are tar, sulphur, resorcin, chrysarobin, 
and pyrogallol. 

Local Treatment of Different Types and Phases of Eczema. — 1 . Acute 
and Subacute Eczema. — In selecting remedies for use on the acutely 
inflamed integument it fs always best to begin with one that is mild 
and soothing, and to make the application to a small surface only, until 
it can be determined that the preparation will operate favorably in 
the case at hand. So greatly do individuals differ in their response to 
a given remedy that it is often well to order an alternative treatment 
in case the first does not prove satisfactory. A remedy that induces 
comfort and brings relief to the patient will usually do good, while one 
that irritates will almost invariably do harm. 



ECZEM I 219 

Cleansing of the Skin. In acute eczema the inflamed skin rarelj 
tolerates pure water. The surface should be washed as little a DO 
sible (often nol al all), and this without soap, and with sofl water that 
has been softened by the addition of borax, soda, bran, oatmeal, gela- 
tin, or other demulcent, as outlined in the description of baths in the 
chapter on General Therapeutics. Hot water tints prepared and 
applied either as a lotion, a bath, a fomentation, or by sponging (with- 
out rubbing), cleanses the part, is frequently grateful, and alleviates 
the itching. When employed otherwise than as a fomentation, its use 
should immediately be followed, as soon as the part is carefully dried, 
by the medicament selected for topical application. During the acute 
stages cleansing of the skin can usually be accomplished best by the 
use of olive- or other oil. For the removal of crusts and other accumu- 
lations a bland oil may be poured frequently over the surface with 
gentle inunction or be applied on lint or gauze. Even the oils, however, 
are at times sources of irritation. They are made more soothing if 
combined with an equal part of liquor calcis to form a liniment. The 
addition of 1 per cent, of phenol makes the mixture antipruritic 
and mildly antiseptic. In many cases the value of these applications 
for the removal of crusts is greatly enhanced by surrounding the whole 
with oiled silk or other impermeable tissue. Such dressing should not 
be applied continuously for many hours at a time, for fear of macerating 
and weakening the skin. Flaxseed, starch, or other poultices may in 
exceptional cases be applied for a few hours at a time to soften crusts 
and other accumulations on the surface. They should not be retained 
long enough to produce congestion and maceration of the skin. 

Powders. — Powders are useful in acute erythematous or papular 
eczema, in intertrigo, and occasionally in vesicular forms of the dis- 
ease. Applied to a discharging surface, pow T ders tend to form coherent 
crusts which retain secretions and are therefore irritating to the skin. 
In early stages, when the discharge is slight, powders will sometimes 
succeed in. wholly arresting the secretion. For this purpose they are 
of special value in mild forms of intertrigo. To prevent friction of 
underwear upon the skin the meshes may be filled with a fine powder. 
In eczema of the hands the gloves may be treated in the same way. 
For absorptive purposes magnesium carbonate is effective. For use on 
dry surfaces zinc stearate, plain or combined with boric acid, salicylic 
acid, thiol, acetanilid, etc., is valuable on account of its lightness, and 
because it will adhere to any surface over which it is lightly rubbed 
with the hand. Among other excellent powders may be mentioned 
talcum, lycopodium, starch, rice-Hour, bismuth subnitrate, zinc oxid, 
and calamin. The following formulae are good: 

1$ — Acid, boric, 
Talc, 
OI. ros., q. s. (i. s. I M. 



lv Acid, boric, 
Zinc stearal ., 
Talc, 
()1. amygdal. amar., q. s. q. s. 



5 '.i ; 

3 v.i ; 


s 


(1. s. 


(|. s. 


5ij; 

3 '.i : 
3 ss ; 


8 

8 
Hi 


q. s. 


(|. s. 



220 HYPEREMIAS AND INFLAMMATIONS 

Anderson's powder and others containing- camphor relieve itching 
better than the simpler powders, hut are usually too stimulating and 
irritating for use in acute eases. In the preparation of dusting-powders 
it is of the utmost importance that they be made impalpable by sifting 
them carefully through silk bolting-cloth, as they are sources of irri- 
tation when they contain gritty particles. Only the best and finest 
grades of zinc oxid, talcum, calamin, and other powders should he 
employed, as many of the coarser grades found in the market cannot he 
rendered fine enough for use by any means at the command of the 
average pharmacist. 

Lotions. Lotion- are among the most valuable preparations in 
acute and subacute eczema, and in some of the chronic forms of the 
disease. They are especially useful in moist eczema, where it is neces- 
sary to protect the surface and relieve the itching, and at the same 
time to avoid the retention of secretions by the dressing. The chief 
drawback of the use of .1 lotion lies in the necessity of its frequent appli- 
cation to prevent drying. This objection may he removed partially 
by the addition of 2 per cent, or more of glycerin or of tragacanth- 
mucilage. The effect of .1 lotion is further prolonged by the addition 
of some impalpable and inert or astringent powder, such as talcum, 
zinc-oxid, bismuth-subnitrate, or calamin. The powder, temporarily 
held in suspension by shaking the lotion immediately before each appli- 
cation, is left as a deposit upon the skin. A similar hut less uniformly 
diffused effect is produced by the use of a dusting-powder immediately 
after the application of the lotion. In moist eczemas a hetter method 
i> to keep the lotion constantly applied, on gauze or other material, 
in the form of wet dressings. Great care must be exercised in the 
removal of such dressings after they have become dry, for fear of wound- 
ing the skin. An effective method is to put a single layer next the sur- 
face, which is removed but once or twice in twenty-four hours or only 
when soiled or stiffened by secretions, while a number of outer and 
thicker layers may be changed frequently in order to keep the dressing 
wet. 

Lotions may be sedative, astringent, or stimulating. Many and 
varied formula? are recommended, but a few only of the most useful 
and typical are given here, together with some suggestions as to their 
occasional modification. One of the most useful lotions, and one that 
is easily procured, is the following: 



-Phenolis, 3ij ; 2 

Zinc, oxid., 3j; 4 

Glycerin., 3ij; 8 

Liq. calcis., q. s. ad. Sviij; q. s. ad. 240 



66 

M. 



The quantity of any one or all of the first three ingredients may be 
increased or diminished as desired. When phenol does not act 
favorably, dilute hydrocyanic acid may be substituted. The zinc may 
be replaced partially or wholly by one of the other powders men- 
tioned above. Glycerin is needed, where phenol is an ingredient, to 



ECZEMA 221 

increase the solubility of the latter drug in the aqueous solution; other- 
wise tragacanth-mucilage may be used Instead of glycerin, or both 

may be omitted and half of the lime-water !><• replaced by an equal 
quantity of elder-flower water. By the use of one or more of these 
suggested changes may be Formed several compound zinc-oxid lotions; 
among the most desirable arc: 



M. 



i; \cid. hydrocyan. 
Zinc, oxid., 
Calamin., 
Liq. calcis, 
Aq. sambuci, 


dil., 


5ss-5ij; 
aa 5j; 
aa oiv; 


2-8 

4 

120 




\\ — Phenolis, 

Bismuth, subnit. 
Tragacanth., 

Liq. calcis, 




3 ss- 5 i j ; 
3j; 

gr. xl; 
q. s. ad. §vnj; 


2-8 
4 
2 
q. s. ad. 240 


<;»; 



M. 

Occasionally, neither phenol nor hydrocyanic acid has the desired 
antipruritic effect, even when increased in strength to 5 per cent., 
or both may be contraindicated for some reason. In such cases 
from 1 to 3 per cent, of menthol, camphor, or chloral may be added, 
with sufficient alcohol to hold them in solution. With these additions, 
however, the lotion becomes more or less stimulating and must be used 
in acute cases with caution. 

The lead-and-opium wash is as useful as the various zinc-oxid 
lotions, and in weeping cases, with burning or hyperesthesia, is usually 
more acceptable: 

1$ — Tinctur. opii, gss; 15! 

Liquor plumbi. sub- 

acetat. dil., q. s. ad. 5 viij ; q. s. ad. 240 1 M. 

To this may be added, as in the case of the zinc-oxid lotion, glycerin, 
boric acid to saturation, zinc oxid, or other powder, to be left on the 
skin as a deposit; or from § to 1 ounce (15. to 30.) of spirits of cam- 
phor, if this is well tolerated and a more decided antipruritic effect is 
desired. 

A saturated solution of boric acid, to which has been added 2 per 
cent, or more of glycerin or tragacanth-mucilage, is an excellent appli- 
cation in moist eczema, and especially in suppurating forms. A weak 
solution of potassium permanganate is both antiseptic and antipruritic. 
Black wash, pure or diluted, is effectual in many moist forms of eczema, 
as are 1 to 10 per cent, solutions of ichthyol and thiol. Excellent 
lotions for soothing effect are made by adding 1 to 2 drachms (4.-8.) of 
sodium bicarbonate or biborate to a quart (1000.) of thin oatmeal- 
gruel or of inarshmallow-decoction. For a dry, irritable, and itching- 
eczema, Boeck recommends the following: 



U 



Talc, 






Amyli., 


aa fi i j ; 


60 


( rlycerin., 


ovj; 


■_>i 


Liq. plumb, subacetat. dil., 


Biv; 


120 



M. 



222 HYPEREMIAS AXD INFLAMMATIONS 

This is to be diluted with 2 parts of water, and applied with cotton or a 
brush. This lotion is decidedly cooling, but is not indicated in moist 
eczema. 

Any one of the zinc-oxide lotions described above may be combined 
with an equal quantity of almond-, olive-, or other oil to form a lini- 
ment. These combinations arc especially good on acutely inflamed 
surfaces of considerable extent, when it is desirable to avoid a drying 
effect. The popular carron oil, compounded of equal parts of linseed 
oil and lime-water, is often objectionable because of the tendency of 
the oil to dry and form a dense coating upon the skin to which it is 
applied. 

For subacute and indolent stages of eczema and for some acute 
cases, mildly stimulating and stronger antipruritic lotions containing 
tar, phenol, menthol, camphor, chloral, and alcohol may be used. 
They should be tried cautiously and diluted at first. As a rule, they 
give best results when applied for a few moments several times a day, 
the part being kept covered in the interval with an ointment or other 
protective dressing. The following formula, which may be modified 
to suit individual cases, are to be recommended : 

6 15 

8 

4-15 



I* 


Phenolis, 

( il\ (crin. 
Menthol., 
Alcohol b, 
Aq. dest., 






5jss 5ssj 
~)i.i: 
oj 5ss; 
q. s.; 
q. s. ad. gviij; 


H 


Liq. picia 
( rlycerin., 

Aq. (lest., 


.Ik: 


lini, 


3ss-5ij; 
3ij; 
q. s. ad. 5viij; 



ad. 240 



M. 



2 s 

8| 
q. s. ad. 240 1 M. 

Liquor carbonis detergens, or Duhring's compound tincture of coal 
tar (these preparations are described under Chronic Eczema) may be 
substituted for the liquor picis alkalinus. Hutchinson recommends 
the following in dry, subacute eczema: 

1$ — Liq. plumb, subacetat., 3«s; 2| 

Liq. carb. detergentis, 5«s; 2| 

Aq. dest., q. s. ad. 5 viij; q. s. ad. 240 1 M. 

Ointments. — Ointments are not, as a rule, well tolerated by an 
acutely inflamed skin, and are commonly more useful in subacute and 
chronic eczema, but there are many exceptions to the rule, and occa- 
sionally even an acute vesicular eczema is best relieved by use of an 
ointment. These should be properly and freshly prepared, and the 
debris of one dressing should be carefully removed before another appli- 
cation is made. Strata of an ointment, the older next the skin pos- 
sibly rancid and having imprisoned beneath them pus or other products 
of disease, are a source of positive harm. In acute, and especially 
in weeping, eczemas an ointment is best applied by spreading it evenly 
on gauze, lint, or other soft material, which can then be laid upon the 



ECZEM I 223 

part. The salve-muslins devised by CJnna furnish an excellent ub ti- 
tute for ointments; they arc clean and effective, and in every way 
admirable if they can be procured fresh. 

Among the best ointments for use on the acutely inflamed skin is 
one containing naftalan. Jt may be employed as follows: oaftalan 
50 j>arts, zinc oxid 25 parts, and amyliim 2"> parts; or the three ingre- 
dients, each 33 parts; or naftalan 25 parts, zinc oxid 12! parts, amy- 
lum 12.} }>arts, and zinc oxid-ointment (U. S. P.) 50 parts. These 
comhinations arc especially valuable in weeping eczemas and are best 
applied on cloths or gauze and held in position with a bandage; the 
dressing being changed twice daily, and the parts cleansed at each 
change with olive oil or white vaselin. Another is the well-known 
diachylon ointment of Hebra. It is prepared as follows: To 14 ounces 
(420.) of the best olive-oil are added 1 pound (480.) of water, and the 
whole heated to boiling on a water-bath; 3 ounces and 6 drachms (114.) 
of finely powdered litharge (oxid of lead) are sifted slowly into the 
liquid, which is then boiled and stirred constantly until all particles of 
litharge have disappeared and there is formed a perfectly homogeneous 
mass. During the cooking, water is occasionally added as required, 
and the whole evaporated to the desired consistence. The stirring is 
to be continued until the ointment is cold. While the mass is cooling 
1 drop of oil of roses or of oil of lavender is added to each 2 ounces of 
ointment. When properly prepared the Hebra ointment is perfectly 
homogeneous, is of a light-yellowish color, and is of the consistency of 
butter. It is technically known as the unguentum diachyli albi of 
Hebra. 

The simple ointment often becomes rancid in two or three weeks, 
but it may be preserved for months by the addition of 0.5 per cent, 
of phenol or formalin. 

Duhring has modified this ointment as follows: 1 part of pure dry 
lead oxid is rubbed down with 1 part of water, and well mixed with 
8 parts of the best olive-oil. The mixture is stirred for about two hours 
over a water-bath near the boiling point, and is then cooled with con- 
stant stirring until the proper consistence is obtained. The ointment 
has been modified by Piffard also, and after him by Kaposi, in combin- 
ing equal parts of lead-plaster and vaselin. It may be imitated fairly 
well by melting together 3 or 4 parts of olive-oil and 4 of diachylon 
plaster and stirring until cool. 

The Hebra ointment, though useful often in full strength and even 
to the exclusion of other pomades, may often be combined with others 
with manifest advantage. Thus, 1 or 2 drachms (4.-8.) of it may be 
added to the ounce (30.) of lard, cold-cream salve, or cerate, with or 
without the addition of another drachm or two of zinc-oxid oint- 
ment. 

The official zinc-oxid ointment is an acceptable preparation in many 
acute easels; equal parts of this and the Hebra ointment make an excel- 
lent combination. Any one of these ointments may be reduced with 
from one to three times its volume of lanolin, vaselin, or cold-cream 



5j; 


30 


onj; 


12 


q. s. 


q. s. 



224 HYPEREMIAS AND INFLAMMATIONS 

salve. The following formula gives an excellent soothing and protec- 
tive ointment: 

T^ — Bismuth, oxid., 5j; 

Vaselin., 
01. oliv., 
( Jerae alb., 
01. ros., a. s. M. 

Other bland and soothing ointments may be made by combining in 
various proportions cold-cream salve, lanolin, vaselin, lard, and simple 
cerate. The cerate- are made sufficiently soft for gentle manipulation 
by adding 1 to 2 drachms (4.-8.) of glycerin or oil to each ounce (30.) 
of ointment, and they may be flavored with lavender, rosemary, or 
bergamot, as preferred. These simple bases may be stiffened and ren- 
dered somewhat astringent by the addition of from 10 grains to a 
drachm (0.66 1.) or more of bismuth subnitrate or subcarbonate, 
zinc oxid, or calamin to the ounce (30.). A very thin base may be 
prepared h\ mixing equal parts of lanolin, olive-oil, and glycerin. This 
is especially valuable for use on hairy surfaces. A creamy and cooling 
base is Qnna's "refringenl ointment/ 1 which contains lanolin, 10; lard 
20; and rose-water, from 30 to 60 parts. Any of the above bases may 
be medicated as desired; the mosl frequent addition being from 5 to 10 
grains (0.33 0.66) of phenol, boric, or salicylic acid, or a similar quan- 
tity of calomel or white precipitate to the ounce (30.) of salve. With 
these unguents may be named glycerole of starch, cucumber ointment, 
emulsion of sweet almonds, decoction of Irish moss, and Hardy's for- 
mula: 2 parts of zinc oxid, 8 of glycerin, 30 of cold-cream salve, and 
15 drops of tincture of benzoin. 

The oleate of bismuth or of zinc is prepared by rubbing up 1 drachm 
(4.) of the oxid of either metal with 8 drachms (30.) of oleic acid, and 
allowing the mixture to stand for two hours. It is afterward heated 
on a water-bath, when 10 drachms (40.) of vaselin and 3 (12.) of wax 
are dissolved in it, and the whole stirred until cold. This ointment 
is especially useful when employed in papular forms of eczema. In 
pustular eczema ointments containing iodoform, boric acid, iodol, 
aristol, or europhen are indicated. 

The Combined Use of Lotions and Ointments will often give good 
results. The black wash as recommended by Duhring, White, and 
others is often effective in acute vesicular eczema. The part is bathed 
for fifteen or twenty minutes tw r o or three times a day w r ith the W'ash, 
the sediment allowed to remain on the skin, and the whole covered 
with a piece of gauze or soft cloth, on which has been spread a thick 
layer of zinc-oxid or other simple ointment. The lead-water or the 
zinc-oxid lotions may be used in the same way with simple ointments 
or pastes. 

Pastes. — Pastes are especially valuable in subacute eczema, and are 
often tolerated in acute forms better than an ointment. A thick paste 
is rarely indicated in moist eczema, as it prevents escape of the dis- 
charge from the surface. Pastes are more cleanly and adhesive, fur- 



ECZEM i 



225 



nisli better protection, arc more drying, and require less frequenl 
application than ointments. They arc formed by combining a simple 
powder, usually insoluble, with an ointment-base, the proportions of 
the two being so adjusted as to produce' a more or less stiff, somewhat 
tenacious mixture, which may he spread as a protective covering 
directly upon tin* skin. The following paste, recommended by I. 
may he taken as a type: 



3— Amyl., 
Zinc. oxid. 
Vaselin., 



oij; 


8 


3ij; 


8 


5ss; 


15 



M. 



The substitution of talc for the starch in the above gives a paste 
with less tendency to concrete in lumps on the skin. Boric acid used 
in place of the starch produces a stiff and adherent paste. A very 
smooth and pleasant combination, and one that is also fairly stiff and 
adherent, is made of equal parts of talc, zinc-oxid, vaselin, and lanolin. 
These pastes serve as bases to which various medicaments may be 
added. Those most commonly used in acute and subacute eczema 
contain boric and salicylic acids and phenol in the strength of from 1 
to 5 per cent.; calomel, white precipitate, ichthyol, and thiol in similar 
proportions. Other remedies may be employed according to the 
indications. The following is an adherent and drying paste: 



1$ — Lanolin., 
Paraffin., 
Cerae alb., 
Aq. dest., 



5j; 
5j; 
5j; 



M. 



The lanolin, paraffin, and wax are thoroughly mixed before the 
water is added. A good drying and soothing paste, recommended by 
Morris, is made of equal parts of almond- or olive-oil, lime-water, and 
zinc-oxid. Unna recommends a paste prepared by mixing 1 ounce 
(30.) of zinc-oxid with 2 ounces (60.) each of glycerin and an official 
mucilage. To either of these pastes may be added 1 per cent, of phe- 
nol or salicylic acid. Another good base is found in Elliot's bassorin- 
paste, 1 which is described in the chapter on General Therapeutics. 

Glycogelatins. — These render excellent service in all dry forms of 
eczema, in which merely protection is required. Certain remedies 
may also be incorporated, such as 1 or 2 per cent, of ichthyol or thiol. 
A convenient formula is the following: 



lr 



-Gelatin, alb., 
Zinc, oxid., 
Glycerin., 
Aq. dest ., 



ty — Gelatin, alb., 
Zinc, oxid., 
Glycerin., 
Aq. dest., 



5j; 

5jss; 

5iij; 

3ijss; 
ov; 

ox; 



M. 



M. 



1 .lour. Cut. Dis., L891, ix, p. 48, and 1892, x, p. 184. 



L5 



226 HYPEREMIAS AND INFLAMMATIONS 

The ingredients are mixed on a hot water-bath and when eool and 
solidified may he cut in pieees of convenient size for use. Before appli- 
catioD a sufficient quantity is melted in a dish placed in a receptacle 
containing water, which is heated to a suitable degree; the liquefied 
material is then applied with a brush, care being taken that it is not 
uncomfortably hot for the patient. It dries somewhat slowly, and it 
is well after two or three minutes to pat the surface with cotton or to 
cover it completely with gauze. By increasing the quantity of glyc- 
erin a softer and more slowly drying preparation is formed. By less- 
ening the quantity of glycerin and increasing that, of the zinc-oxid or 
gelatin, a firmer and more rapidh drying product is obtained. Though 
these glycogelatins serve their best purpose in the dry forms of the 
disease, there are few forms of eczema in which they may not at times 
be used with benefit. 

In subacute and indolent types Pick's Gelatin Sublimate is useful. 
This is prepared by mixing 30 grammes (gj) of gelatin with sufficient 
water to liquefy it on a water-bath, and evaporating to 75 grammes 
(Sijss); after which 25 grammes (5vj) of glycerin and 5 centigrammes 
(gr. |) of corrosive sublimate are added. The product must be melted 
before applying. 

In acute erythematous eczema Tick's Tragacanth \'ur)iisli ("/////- 
mentum exsiccans") i> a very acceptable remedy, in that it is easily 
applied without heating, dries quickly, is cleanly, and distinctly cooling. 
It is composed of tragacanth. 5 parts; glycerin, 2 parts; and boiling 
water, 93 parts. To this may be added from \ to 2 per cent, of boric 
acid or phenol, or from 2 to 5 per cent, of some simple powder, such 
as zinc-oxid. The tragacanth must be soaked for several hours in a 
part of the water and thoroughly triturated before the other ingredients 
are added. Stelwagon 1 prefers a varnish containing zinc oxid, 2 parts; 
glycerin, 1 part; and mucilage of acacia, 5 to S parts, as it dries more 
quickly than the tragacanth. 

2. Subacute Eczema. — Attention has already been called to the 
fact that no sharp line can be drawn between acute, subacute, and 
chronic eczema, the degree of inflammation in any given case varying 
from time to time. Most acute cases, however, are followed by a 
longer or shorter period of subacute or chronic inflammation. In 
proportion as the disease progresses to the subacute or chronic stage, 
the various topical medicaments employed may be changed in char- 
acter so as to produce an astringent or stimulating effect upon the 
part. The utmost skill and prudence, however, are needed at this 
juncture, and changes should be made cautiously, for it is at this time 
that the disorder is readily awakened to renewed activity, a turn of 
affairs which is especially annoying to the patient, and particularly 
so to the practitioner if there be a suspicion (often too well founded) 
that the aggravation has been due to the treatment. 

Again, many cases of eczema are subacute and indolent from the 

1 Diseases of the Skin, 7th ed., p. 311. 



ECZEMA 227 

beginning, yet arc liable at any time to present acute manifestation 
consequently, in beginning the treatment of an apparently subacute 
case, it is well to use mild measures first, gradually changing to those 
stronger and more stimulating. 

The treatment of subacute eczema varies from that of the acute 
type chiefly in demanding more stimulating remedies and those hav- 
ing a greater antipruritic effect. For this purpose many of the sub- 
stances already recommended for acute eczema may be employed, 
but in increased strength. In this phase of the disorder pastes are 
especially valuable, as are also the glycogelatins, though occasionally 
lotions and powders produce the best results. On the other hand, 
cases occur in which ointments make the best applications. When 
milder measures will not succeed in a given case, the stronger remedies 
recommended for chronic eczema should be employed. 

:5. Chronic Eczema. — The general principles of local treatment 
of chronic eczema are those of the acute form of the disease, except 
that stronger and more stimulating remedies are used. It must be 
remembered that many chronic eczemas are subject to acute exacer- 
bations, when milder and soothing treatment must be adopted for a 
time. Moreover, chronic eczema appears in such varied phases in 
different individuals, and in the same individual in successive attacks, 
that it is impossible to select certain formula? and declare that these 
will be of benefit in a given type of the disease. It is only by careful 
observation of the general principles and objects of the treatment of 
eczema, discussed in the preceding pages, that the varied conditions 
can be successfully treated. 

Cleansing of the Skin. — This should be accomplished according to 
directions already given, by means of oils or liniments, though in chronic 
eczema more vigorous measures can frequently be employed, including 
the occasional use of soap and water, some densely infiltrated patches 
tolerating and even being benefited by a daily washing. For this 
purpose a good toilet-soap, or, w T hen the skin will permit, tincture of 
green soap, may be used. The Sarg glycerin soap is an admirable 
substitute for these articles when the skin is tender and where a 
refined toilet-preparation can be ordered. The crusts and scales once 
removed, subsequent topical applications can be made as required in 
each case. 

Powders. — Powders are useful in chronic as in acute eczema for 
mechanical protection, to prevent friction between apposed skin- 
surfaces or between the skin and clothing. They are often of value 
when dusted and patted over a paste, thus making a thicker and more 
cleanly dressing, and one less likely than a paste to be rubbed off. 
The Anderson and other antipruritic powders are frequently sen ice- 
able for application during the day, when other dressings cannot well 
be employed on account of the patient's occupation. 

Lotions. — Lotions are of less value in chronic than in acute eczema, 
but are often useful for temporary purposes after the skin lias been 
unduly irritated bv other dressings. Stimulating lotions or solutions 



228 HYPEREMIAS AND INFLAMMATIONS 

are sometimes painted on the skin and allowed to dry, or are used 
for a few minutes each day, the surface in the intervals being covered 
with an ointment. 

Ointments. — Ointments are the preparations most used, especially 
in the dry, scaling forms of the disease, in which penetration of the 
remedy is desired. To serve this end, they should be gently rubbed 
into the surface, which is later covered with more 1 of the same ointment 
spread on gauze or a soft cloth. 

Pastes. Pastes often answer better than ointments, especially when 
protection and drying of the surface are the chief objects of treatment. 
In combination with powders, as described above, they furnish con- 
venient and effective applications in most cases of chronic eczema. In 
many dry forms of the disease cither plain or medicated glycogelatins 
furnish the best application. They are of special value in dispensary 
and other cases in which the physician docs not wish to entrust the 
dressing to the patient, as a gelatin-dressing may often be left in place 
for several days or a week. For the application of tar, chrysarobin, 
salicylic acid, and a few other remedies to small areas, collodion and 
fluid gutta-percha (traumaticin) form convenient and cleanly vehicles. 

Applications in chronic eczema, as a rule, should be more antipruritic 
and more stimulating than in acute and subacute phases of the dis- 
ease. The remedies recommended above may be used in increased 
strength. This LS especially true of the drugs classed as antipruritics, 
such as phenol, creosote, camphor, menthol, and chloral. 

Salicylic acid is one of the most useful remedies in chronic eczema. 
It is antipruritic and is effective in destroying thickened areas of dry, 
horny epidermis. It may be incorporated, in the strength of from 2 to 
10 or even 20 per cent., in most of the ointments, pastes, and plasters 
recommended in the preceding pages. In the glycogelatins more than 
2 or 3 per cent, cannot be used without the addition of a fat, prefer- 
ably 5 per cent, of fresh lard. For small areas of infiltration, with 
marked thickening of the horny layer, salicylic acid is best used with 
Dnhring's modifications of Pick's salicylated soap plaster. The acid 
has a tendencv to soften the plaster if employed in strength above 
5 per cent. The formulae are as follows : 
J£ — Emplast. saponis (U. S. P.) 



liquefact., 
01. olivse opt., 
Acid, salicylici, 


5iij; 

f3ij: 

3ss; 


a 5 per cent, plaster: 




1^ — Emplast. saponis (U. S. P.) 
liquefact., 
01. olivae, 
Acid, salicylici, 


5i; 

Ttlxxiv; 
gr. xxiv; 



M. 



60 
60 M. 



For a 10 per cent, plaster: 

1$ — Emplast. saponis (U. S. P.) 

liquefact., 5j; 30 

Acid, salicylici, gr. xlv; 3 



M. 



ECZEM I 229 



'or ;i 20 per <rii( . plaster: 



1$ Emplast. plumbi (U. 8. P.), 5j; 301 

Cera flayae, xlv; 3 

Acid, salicylici, gr. xc; 6 M. 

Plasters made according to the above formula; are adhesive, and 
are firm enough to be moulded and kept in rolls. For large surfaces 
they should be warmed before being applied, to make them spread 
easily. Resorcin and other remedies may be substituted for salicylic 
acid, but resorcin has a tendency to stiffen the plaster and requires 
the addition of oil. I nna's salicylated gutta-percha plaster-mulls 
make excellent substitutes for the above, but to be serviceable they 
should always be fresh. 

Tar. — This is one of the most valuable remedies, when tolerated by 
the skin, for the treatment of chronic eczema. The preparations most 
commonly employed are pix liquida (pine-tar), oleum rusci (oil of white 
birch), oleum cadinum (oil of cade), and terebinthina Canadensis 
(balsam of fir). Oil of cade, as found in most of the shops, is inferior 
to oleum rusci. The tars are best applied in the form of ointments, 
but are occasionally painted with a camel's-hair brush over the affected 
surface in a liquid state. From J to 2 drachms (2.-8.) of tar, in com- 
bination with a suitable quantity of potassium subcarbonate, are suf- 
ficient to add to 1 ounce (30.) of ointment, the proportions suggested 
being varied to suit the requirements of each case. 

In beginning the use of tar with any individual, weak preparations 
should first be employed, and the strength be gradually increased until 
tolerance of the skin is determined, as an acute dermatitis not infre- 
quently follows the application of stronger preparations. A conveni- 
ent method is to order one jar of a fairly strong tar-ointment, and 
another of the zinc-oxid, the Hebra, or other simple salve. Before 
the first application the patient takes a sufficient quantity of the simple 
ointment and mixes with it a very small proportion of the tarry prep- 
aration. If no irritation follows this application, the amount of tar 
can be gradually increased with each dressing until enough is used to 
relieve the itching and to reduce the infiltration, after which a simple 
paste or powder may be employed until the skin has regained its normal 
strength and resistance. If the application at any time cause's an 
acute dermatitis, simpler remedies for a time must be substituted. 
To accomplish the best results, tar-ointments should be rubbed well 
into the skin or liquid preparations painted on. Sometimes it is well 
to permit the application to accumulate until thrown oil' by exfolia- 
tion, but it is better to cleanse the skin with oil or with soap and water, 
according to indications, before each application. 

The following formula? are illustrations of the manner of compound- 
ing the various preparations of tar: 



M 



ly 01. rusci (vel cadini), 


5ss ~)iij; 


2 12 


Potass, bicarbonal ., 


i').i 5ss; 


1 33 2 


Unguent, aq. ros., 


5j; 


30 


Ft. ungt. 







230 HYPEREMIAS AND INFLAMMATIONS 

For the potassium bicarbonate J to 1 drachm (2.-4.) of zinc-oxid 
may be substituted, or from 2 to 4 grains (0.133-0.266) of red mercuric 
oxid, or yet \ scruple (0.66) of mild chlorid. The vehicle, also, of 
such ointments may be vaselin, lanolin, simple cerate, or \ ounce 
(15.) of either in combination with an equal quantity of diachylon 
ointment. 

Of fluid preparations may be mentioned alcoholic solutions of tar, 
\ ounce I L5.) of the latter to the pint (500.) of alcohol; and in cases in 
which the detersive action of soap is also needed sapo wridis may be 

added as follows: 



M. 



T$ — Picis Liquids, 


fShSij; 


30-60 


Saponia mollis, 


fSjss-giij; 


i:> 90 


( rlycerin., 


f5j; 


30 


Alcoholis., 


fjviij; 


240 


( )l. rosmarin., 


f3ss; 


2 



Sig. To be rubbed gently into the skin with a flannel rag. 



Bulkley devised an alkaline solution of tar and caustic potash, 
which is especially serviceable) as it is miscible with water in all pro- 
portions. It is constituted as follows: 

H Picia liquidse, f.lij; 60 

Potasse caual icse, ,"> i ; 30 

Am. <lcst., gv; 150 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar 

with friction. 
Sig. Liquor picis <ilk<dinus. To be used diluted as a lotion. 

Of this solution 1 drachm (4.) or more may be added to a pint (500.) 
of water. For an ointment, the same quantity of the solution may be 
added to the ounce (30.) of cold-cream salve, lanolin, or vaselin. It 
should be remembered, however, that the caustic alkali renders this 
preparation exceedingly irritating to a sensitive skin, and it should be 
employed with caution upon any untested surface. 

An excellent fluid preparation is Duhring's Compound Tincture of 
Coal-tar, prepared according to the following formula: "Coal-tar (1 
part) should be digested with tincture of quillaja (6 parts), with fre- 
quent agitation, for not less than eight days, preferably for a longer 
period, and finally filtered. The resultant product is a brown-black 
tincture, which, upon the addition of water, forms a cleanly, yellowish 
emulsion, the color and certain other characters varying with the 
variety of coal-tar used. The strength of the tincture of quillaja 
should be 1 to 4 with 95 per cent, alcohol." Five to 15 minims to 
the ounce (0.33-1. to 30.) of water is the strength recommended 
for use. 

The formula recommended by Spencer, and described in the chapter 
on General Therapeutics, is a useful means of testing the efficacy of 
tar upon an eczematous surface. Olive-oil or cod-liver oil may be 
combined with equal parts of one of the tarry preparations and rubbed 
into the eczematous skin. When fluid or semifluid compounds of tar 
are needed upon the scalp, 1 drachm (4.) of the article selected may 



5iv; 


120 


5j; 


30 


o ss ; 


15 1 



ECZEMA 231 

be nibbed up with an equal quantity of glycerin and added to 6 ounce 
(180.) of cologne-water. Creolin is very similar in its action to tar 
and is miscible with water. 

Ilebra disclaimed any special value for sulphur in eczemas uncom- 
plicated by the Acarus SCabiei, but in Wilkinson's and other ointment 
it serves a good purpose. The following formula supplies an ointment 
Hither less severe that has practical efficacy in chronic eczema : 

1$ — Picis liquid, (vel. ol. nisei), 

Adipis, 

Ol. olivse, 
Misce el adde: 

Terebinth. Canadens., 

Sulphur, flor., aa 5j; aa 30 1 M. 

Sig. — To he applied three times daily with a soft brush. 

To this formula may he added green soap, if a stronger effect is 
desired. 

('rude coal-tar 1 is a valuable preparation in chronic eczema. It has 
been useful also in some eases of the acute type. Ointments and 
pastes containing 10 to 30 grains (0.66-2.) of sulphur, and 5 to 15 
grains (0.33-1.) of salicylic acid to the ounce (30.) often give good 
results in circumscribed, infiltrated patches of eczema, which show 
tendencies to occasional moisture and crusting. Ointments containing 
from 1 to 4 per cent, of sulphur favor keratoplasia. 

Ichthyol and thiol, in ointments of the strength of 10 per cent, and 
less, or in aqueous lotions containing from 5 to 50 per cent, of the drug, 
arc useful in localized patches of the disease, especially of the papular 
and scaling varieties. Ammonium ichthyolsulphonate is preferable to 
the sodium compound. Its influence upon the skin seems to resemble 
both that of the tars and of chrysarobin. Unna's varnish containing 
ichthyol is convenient, as it dries rapidly and is easily removed by 
washing. It is prepared as follows: 40 parts of starch are mixed with 
100 parts of water, to which are added 40 parts of ichthyol; after thor- 
ough trituration there are added 1 J parts of a concentrated solution of 
albumin, which should be prepared at a temperature low enough to 
prevent coagulation. 

Other remedies which may be added to ointments, pastes, or plasters 
(in strength varying from 1 to 10 per cent.) for the treatment of chronic 
eczema are: resorcin, chrysarobin, pyrogallol, calomel, and ammoniated 
mercury. Occasionally, systemic intoxication has followed the use of 
these remedies over large surfaces, and they are adapted best to em- 
ployment on small areas. The three first named stain the skin and 
clothing. Other preparations of mercury may be employed with 
advantage in some cases. 

In persistent areas, with marked infiltration of the skin, radiotherapy 
often gives excellent results. We have found it of value most fre- 
quently in the dry, scaling forms of the disease, but it is indicated also 

1 Sutton, Jour. A.mer. Med. Assoc, A.ugus1 8, L908, p. 197; Rygier and Miller. 
Archiv, October, L912 (abstr. Brit. Jour. Derm., L913, vol. xxv, p. 73). 



232 HYPEREMIAS AND INFLAMMATIONS 

in moist forms with infiltration, and especially in eases in which sup- 
puration is present. The technique is the same as that recommended 
for psoriasis. 

An effective method of treating circumscribed thickened patches of 
eczema is the following: A piece of green soap as large as a walnut is 
spread upon a flannel rag and rubbed into the eczematous pari for 
several minutes, pressing firmly the while, and from time to time dip- 
ping it into water in order to produce lather. The duration and firm- 
ness of the rubbing depend chiefly upon the amount of infiltration 
present, hut to some extent upon the general condition of the skin. 
The production of an acute dermatitis by too severe treatment should 
he avoided. Following the soap-rubbing, the part is washed free from 
suds with water, carefully dried, and the oil or ointment selected for 
topical use immediately applied on strips of muslin, which are neatly 
bandaged to the part. Hebra's diachylon ointment is one of the best 
for this purpose. The soap must he rubbed in at least twice every 
day, so long as any excoriated points appear after its application. 
Soap rubbed into the healthy skin will not he followed by such effects, 
the part feeling clean, smooth, and comfortable after it has been washed. 
The contrast this offers i<> the eczematous patch i> very striking, the 
latter representing numerous intensely red, raw, and moist spots. 
The appearance <>f these red, shining, moist points after the first 
inunction suggests t<> the inexperienced eye that the malady has been 
aggravated; but they become fewer in Dumber after each application, 
and filially disappear, the eczematous surface being then no more 
affected by the soft soap than i> the surrounding healthy skin. 

Among the more severe measures occasionally employed for small 
patches of eczema which resist milder treatment may be named: can- 
tharides employed as a blister; silver nitrate in crayon or in solution, 
from ."! to b<) grains to the ounce (0.2-4. to 30.); and iodin in com- 
bination with phenol. The following formula should furnish a clear, 
vinous-red fluid, which may be applied pure or in dilution: 



M 



In cases in which there is considerable itching, especially in obsti- 
nate patches of papular eczema, the iodized phenol of Bellamy may be 
substituted for the above. The formula is: 

1$ — Phenolis., 

Iodini cryst., aa 5JJ aa 4[ 

Combine with gentle heat and add an equal part of glycerin. 
Sig. — Iodized phenol; to be applied twice daily with a glass rod. 

Prognosis. — Eczema is an entirely curable disease, but uncertainty 
attends its prognosis as regards the duration of an attack and the prob- 



1$ — Iodin. tinct., 




3ss; 




2 


Phenolis (cryst.), 




3i; 




4 


Glycerin., 










Alcoholis, 




aa 3ij; 


aa 


8 


Aq. dest., 




ad fgj; 


ad 


30 


Sig. — Iodized solution 


of phenol. 







TOPICAL AND SPECIAL VARIETIES OF ECZEMA 233 

ability of a relapse. With respecl to the questions mosl frequently 
asked, those relating to contagion, heredity, and persistent le ion- 
relics, a favorable response can be made; l>nt the fad remains thai 
some forms of the disease are insignificant, some persistent, and some 
particularly liable to recurrence from very slight provocation. Only 
after careful weighing of all the conditions exhibited by the skin and 
by the other organs can a reasonable probability as to the future of the 
disease be estimated. Eczema is a disease exceedingly common, and 
one subject to aggravation by causes well-nigh innumerable. Were 
the physician always in position absolutely to insure his patient a 
proper mode of living, and the exclusion of all sources of irritation of 
the skin, the prognosis would be much 'more satisfactory. In hospital- 
patients, over whom such control is more perfectly attained, the results 
of treatment may be predicted with some confidence. 

In general, it may be said that acute eczema is more readily relieved 
by proper treatment than are the chronic forms of the disease; that 
eczema with a discoverable cause is more manageable than one the 
etiology of which is obscure ; that eczema of the very young and of the 
very old is at times particularly rebellious; that the non-discharging 
phases of the disease are rather more persistent than those accom- 
panied by secretion; that eczema lingering at the mucous outlets of 
the body (auditory canal, nostrils, mouth, nipple, anus, vagina) is 
more obstinate than when it affects the skin of other parts (shoulders, 
neck, lumbar region) ; that eczema with constant aggravation or com- 
plications (fissure of skin of hand, varicose veins of leg, surgical 
apparatus) is more stubborn in proportion as these complications or 
aggravations cannot, from the circumstances of each case, be set aside; 
and, finally, that an eczema which has long existed, or has repeatedly 
recurred, as, for example, with every season of extremely cold or hot 
weather, is, after relief, very liable to return. The parasitic eczemas 
are particularly amenable to treatment. 

TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 

Eczema of Children. — Inflammation of the skin in infants and 
young children is usually acute in type, owing to the delicate structure 
of the skin and to the tendency in childhood to acute rather than 
subacute and chronic pathological changes in the various organs of 
the body; consequently, the eczema of infants is commonly vesicular, 
pustular, or vesiculo-pustular in expression. Though acute in type, 
eczema of young children is frequently chronic induration; a child, for 
example, of two, three, or four years of age may have had the disease 
in varying degrees and extent since a few weeks after its birth. In 
these persistent cases there may be considerable thickening and infil- 
tration of the skin, and periods during which the symptoms are those 
of a subacute or chronic process; but acute manifestations recur at 
frequent intervals and usually predominate. 

The causes peculiar to eczema of childhood arc found in the ease and 



234 HYPEREMIAS AND INFLAMMATIONS 

frequency with which the delicate skin is injured by external agents, 1 
such as soap, hard water, rough clothing, dirt, and pathological secre- 
tions, together with the rubbing and scratching that follow itching 
from any cause; in the presence of toxins in the blood, resulting from 
deficient elimination or from imperfect metabolism and assimilation 
of food, due commonly to improper or irregular feeding, and from 
various systemic diseases; in the so-called reflex irritation arising from 
dentition; and in the local infections of the skin with pns-cocei and 
probably at times with other microorganisms. According to statistics 
gathered by Crocker, more than one-third of all cases of eczema in 
children begin during the fir^t year of life. 

Treatment.- Success in the* treatment of these young patients 
depends, first, upon the painstaking search for, and removal of, the 
causes; and, secondly, upon the care with which the principles of treat- 
ment of acute eczema, already set forth, are carried out in all details. 
Special attention should he given the question of diet, and every effort 
should be made to prevent autointoxication of intestinal origin. In 
the local treatment gentle measures should he the rule. 

Eczema of the Scalp I Eczema Capitis, Eczema CapUlitii). — Symp- 
toms. When the scalp is affected with eczema the symptoms differ 
somewhat according to the age of the patient. In adults the erythem- 
atous and squamous varieties of the disease are more common; in 
Infants and children the pustular variety. In the former the eruption is 
usually circumscribed and in patches; in the latter it is more diffused. 
In the same proportion, also, the former is generally asymmetrically, 
and the latter symmetrically, developed. 

In infants and children the pustules rupture early and their contents 
dry into dirty-whitish, yellowish or greenish crusts, matting the hairs, 
thus serving as foci for dust-accumulation and as nests for lice. The 
crusts superimposed upon a reddish, oozing, pus-covered, or occa- 
sionally indolent skin, often foul-smelling, and usually complicated 
by a seborrhea. The so-called "milk-crust" is usually a compound of 
dried pus and altered sebum. The itching is not so intense as in some 
other forms of the disease. Postcervical, pre-auricular, and occipital 
adenopathy is common, and in strumous children suppuration of the 
affected glands may occur. The causes of this form of disease are 
evidently associated with local conditions. The rapidly growing hairs 
of the scalp are in intimate association with the numerous and large 
sebaceous glands of the same part, which at times unquestionably 
respond by an exudative process when a relatively slight external irri- 
tation is added to the physiological stimulus they feel. Such local 
irritants are often not wanting to push the disturbed equilibrium into 
the scale of disease. White calls attention to the common neglect in 
removing the "pre-natal cap of cheesy material," as well as to rude and 
unskillful attempts to accomplish the same end. Extremes of tem- 

1 Hall, Brit. Jour. Derm., 1905, xvii, pp. 161, 203, 247 and 287, and ibid., 1908, xx, p. 4. 

2 Winfield, Jour. Amer. Med. Assoc., 1908, 1, p. 1993; Simpson, ibid., 1912, lviii, 
p. 995. 



TOPICAL iND SPECIAL VARIETIES OF ECZEMA 235 

perature, friction, excess, neglect, ;ni<l absence of endeavor to wash 
the scalp all contribute to originate or to aggravate the disorder. 
The affection when complicated or induced by lice is more common 

in children than in infants, doubtless in consequence of tlie greater 
independence of the former and their gregarious habits. In girls with 
relatively long hair, the ova, or nits, of the parasite are readily distin- 
guished adhering closely to the hairs, and accumulated especially 
about the occipital region. The itching is usually more annoying 
than in pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhea when scratching 
has been practised or irritant applications have been made. The 
eruption here usually occurs in asymmetrical patches, or it may be 
limited to a single patch, tolerably well defined in outline, often upon 
one side of the scalp, not, as in infancy, preferring the vertex. 

Diagnosis. — The diagnosis of these forms of disease has been already 
considered. The disorders most commonly confused with eczema of 
the scalp are psoriasis, dermatitis seborrheica, favus, and trichophytosis 
capitis. 

Treatment. — In the treatment of eczema of the scalp in infants and 
children the first indication to be met is the removal of the accumulated 
crusts. When this removal is harshly accomplished, it becomes a fruit- 
ful source of further mischief; it is therefore necessary to proceed with 
great gentleness. The thorough softening of the crusts is all-impor- 
tant. For this purpose it is necessary to soak them with oil and to 
retain this substance in intimate contact with the scalp. Olive- or 
cod-liver oil may be selected, and, if needful to correct the odor or for 
other purposes, 1 drachm (4.) of phenol may be added to each pint 
(500.), with 2 drachms (8.) of the balsam of Peru. A neat-fitting 
skull-cap, constructed of suitable impervious material, should then 
be applied smoothly, and fastened in place by a light bandage, never 
by elastic-rubber bands. After several hours of soaking the crusts 
should be removed with warm water and spirit-of-soap washing, and 
the entire process be repeated until the crusts are completely detached. 
In selecting an article for subsequent medication of the scalp, it should 
be remembered that even infantile eczema will proceed to a natural 
involution if unirritated; hence, oleated lime-water, or oil of sweet 
almonds alone will often answer better than an ointment, and, even 
where there is considerable acuity of the inflammatory process, lime- 
water alone, with possibly a small quantity of glycerin added, will be 
effective. As the discharge and crusting cease, ointments instead of 
oils and lotions may be employed. The ointment is to be rubbed 
gently over the surface with the tip of the finger, and the skin after- 
ward protected with suitable dressing, such as a gauze-cap. Good 
ointment-bases for use on the seal]) are lanolin, vaselin, equal parts of 
lanolin and oil, or equal parts of glycerin, lanolin, and oil. The fol- 
lowing remedies may be incorporated in strength varying from 1 to 5 
per cent.: phenol, salicylic and boric acids; calomel, ammoniated 



236 HYPEREMIAS AND INFLAMMATIONS 

mercury, ichthyol, sulphur, resorcin, and tar. In children and in 
acute cases strong preparations must not be used. When the sebor- 
rheal element is at all pronounced the treatment is that of seborrheal 
dermatitis. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it is a more expeditious method of arriving at the end, 
when a nurse has to dress the heads of several children in a single ward. 
Lice when present may be destroyed by the application of petroleum, 
bichlorid lotions, or alcohol. The nits are removed with dilute 
acetic acid, alcohol, or cologne-water from hairs which it is not desir- 
able to cut. In adults, especially in women, the hair should be spared, 
while the patient is warned that the lo>s of the growth upon the seal]) 
may be considerable. Where an obstinate pityriasis steatoides is 
followed by eczema, the latter may be succeeded by alopecia; in the 
absence of the former the hairs usually are reproduced. It is rarely 
necessary to employ the sknll-cap in adults, since one can succeed in 
insuring the necessary applications by directing the attention of the 
patient to the necessity for care and thoroughness. 

As the disease in both classes of patients advances to a subacute or 
chronic stage the treatment may be made more stimulating. In the 
case of infants, however, stimulating topical remedies are very rarely 
to be employed. An eczema of the scalp in an infant or a child that 
has once entered upon resolution should generally be soothed and 
protected. 

Many children thus affected are in excellent general health, and 
require no internal medication. Proper nourishment, elimination, and 
hygienic surroundings should be sought in every ease. 

The treatment of erythematous and chronic eczema of the scalp in 
adults i> described under Dermatitis Seborrheica. 

Eczema of the Face (Eczema Faciei). — Symptoms. — Erythematous 
eczema of the face in adults is projected prominently among the vari- 
eties of the disease by its uniformity of type. It occurs in early and 
middle life and in advanced years, and is a particularly intractable 
ailment. In well-marked cases the forehead, cheeks, eyelids, and nose 
of the patient are involved, exhibiting an infiltrated, usually dusky- 
red, often symmetrical, patch of disease, the affected surface being 
slightly elevated above the level of sound skin. This surface is uni- 
formly smooth and reddened; occasionally, near the root of the nose 
and about the lower line of the forehead, minute, closely-set papules 
are visible. Very slight oozing, especially after irritation, may be 
noticed. At the height of the disease, or in its involution, exceed- 
ingly fine scales form, which are scarcely perceptibly shed from the 
surface. The eyelids, especially the lower lids in advanced years, 
become puffy. The line of demarcation of the attacked surface is 
unusually distinct, and rarely invades the scalp-border or the region 
of the beard. Itching is at times intense, the patient bitterly com- 
plaining of it, and usually preferring to rub the face with the hands or 
with pieces of cloth. Sometimes, however, the face is well scratched 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 23< 

with the finger-nails, and excoriations and blood-crusts disfigure the 
countenance. Patients of intelligence usually describe the itching as 
paroxysmal and as starting al the root of the nose, whence it travels 
upward over the forehead and laterally to the brows, often in the line 
of the supraorbital nerves. At the root of the nose the exudative 
process is most marked. The eruption is seen also in asymmetrically 
disposed patches of various sizes, with islets of sound skin between. In 
typical cases the hairs of the eyebrow are reduced to a stubble by con- 
stant rubbing. In resolution of the symmetrical form this condition 
of the eyebrows is commonly observed. 

Patients thus affected are often those whose faces have especially 
been exposed to irritation, such as locomotive-engineers, pilots of sea- 
going vessels, mechanics in trades in which the hands are soiled with 
irritants and afterward applied to the face, and women spending hours 
of each day over the laundry-tub or the kitchen stove. In each class 
the operation of the cause is made manifest by the exacerbation of 
the disease after exposure. 

In patients of younger years and especially in infants the face is apt 
to display vesicular and pustular types of the disease, forms more 
often of acute eczema, and correspondingly more manageable. 

The itching, and especially the burning, sensations are prone to be 
severe, and crusts rapidly form. In infants the picture presented is" 
often similar to that seen in the scalp, except that there are no hairs 
to be matted into crusts and there is often a reddish blush at the edge 
of the patch or where the crust has been removed, the redness of the 
oozing surface being somewhat more marked than in the similar patches 
on the less vascular scalp. The scratching in these patients is 
severe, crusts being torn off in part or wholly; blood-crusted excori- 
ations are common. In this way the area of surface involved is clearly 
extended, sleep is greatly disturbed, and the irritability and fretfulness 
of the child bear heavily upon its general nutrition. In severe cases of 
long standing the mental tone of these sufferers becomes singularly 
perverted and their character unquestionably changed. The eczema 
of the cheeks and chin of infants appears at times to stand in close 
relation to the eruption of the teeth. Hall 1 found that in 96 per cent, 
of infantile eczemas the face and scalp were the points of origin. 

Diagnosis and Treatment in Adults. — The affection is most commonly 
mistaken for erysipelas, a disorder from which it is readily differ- 
entiated by the chronicity of its course. The latter feature is particu- 
larly characteristic of this form of eczema, which is rarely completely 
relieved, after the age of sixty, within a twelvemonth, and which, 
when it has existed for a long period of time, is particularly obstinate' 
under the best treatment, recurring with exasperating frequency upon 
exposure of the face to atmospheric changes. The great vascularity, 
abundant supply of sensory nerves, and necessary exposure of the face 
explain this peculiarity. In its management the lotions and dusting- 

1 Loc cit. 



238 HYPEREMIAS AND INFLAMMATIONS 

powders described under the treatment of acute eczema fulfill an 
important part. In some cases pastes, ointments, plasters, or the 
glycogelatins give better results than lotions and powders. Soothing 
applications should always be first employed; and more 4 stimulating 
applications may be tried later. In main - cases Pick's linimentum 
exsiccans or tragacanth-glycerin mucilage furnishes a pleasant and 
effective application. 

In obstinate cases tar and other stimulating remedies recommended 
for chronic eczema should be employed. It is well to remember in the 
management of any case that, while a tarry application may be well 
tolerated over one part, as, for example, on the cheeks and near the 
nose, in another part, such as over the eyelids, a zinc-salve may 
better be employed in the same individual. 

Treatment in Infants. In the management of infantile eczema of the 
face, the points of importance arc avoidance of all external irritating 
applications, including soap and water; the removal of crusts and 
debris with olive or other oil or white vaselin; and the application of 
soothing preparations held in position with a mask. The dressings 
arc best retained in position by using a sknll-cap, made of firm, old 
cotton or linen cloth, which is closely fitted to the calvaria, and a mask of 
the same material is shaped to the face, with exactly placed apertures 
for t he e\ (•-. nose, month, and ears. This mask is gathered in beneath 
the chin, and laps over two inches at the back of the head; it may be 
used only during sleep, or, in aggravated cases, also during the day. 

The lotions, oils, or ointments required are placed on pieces of soft 
cloth, applied to the face, and the above described device used to hold 
them in place. To prevent scratching of the face, splints should be 
applied extending from the middle of the forearm to the middle of 
the arm on the flexor surface. The application of most value in these 
cases is naftalan, used as before mentioned in acute eczema. The zinc- 
oxid and lime-water lotion or the calamine lotion are valuable, also the 
following oily cream: zinc oxid S parts, bismuth subnitrate 4 parts, 
olive oil 120 parts, and aqua calcis 120 parts, in addition the black- 
wash and zinc-salve treatment, the diachylon salve, Lassar paste, 
boric-acid ointment, lead lotions, glycerole of starch, and other prep- 
arations and methods described in full in the treatment of acute 
eczema. These cases are often very capricious in their course, and 
treatment may have to be changed frequently to meet the varying 
conditions. 

Eczema of the Lips (Eczema Labiorum). — Reference has already 
been made to the obstinacy of eczema occurring near the mucous out- 
lets of the body, a result due, probably, to the secretion furnished by 
the adjacent mucous tracts. The lips furnish an illustration alike of 
this pertinacity and aggravation. Their frequent motions in masti- 
cation and articulation aggravate an eczema, which is, moreover, apt 
to be teased by a no less frequent thrusting out of the tongue (where 
there is no beard) to wet the parts with mucus and saliva. Vesic- 
ular, pustular, squamous, and erythematous lesions occur at one 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 239 

point or along the entire line of the lip, with frequenl ly resulting cm I 
and fissures. The vermilion bonier of the lips commonly participate 
in the process. The lips become hot, and sometimes much thickened 
by the swelling and infiltration, their niueous faces being rarely im- 
plicated. Scarlet, dull-red, and peculiarly purplish hues of the 
vermilion border become visible. The parts are more picked than 
scratched, though the Itching at times is severe. The pustular and vesic- 
ular forms are more common in children. The erythematous form, 
its reddened outline roughened by scales evenly projected beyond the 
vermilion border, is rather an affection of maturer years. In many 
cases the disease is aggravated by nasal discharges which flow over the 
upper lip, giving the latter an elephantiasic aspect. In eczema of the 
hairy lip the symptoms and treatment are those of eczema barbae. 

Diagnosis. — The diagnosis is between hyphogenous sycosis, herpes 
labialis, epithelioma, and syphilis. The first is accompanied by loosen- 
ing of the hairs, caused by a vegetable parasite; the second is vesicular 
in lesion, brief in duration, and trivial in severity; the third is a disease 
of advanced years rather than of early and middle life, and is accom- 
panied by characteristic induration and ulceration and not by itching. 
Syphilis frequently attacks the angles of the lips; in most cases when 
thus limited, typical mucous patches of the mouth can be discovered. 
The lesions of syphilis at the angles of the mouth are seldom linear 
fissures, but are more often definitely outlined erosions, secreting a 
puriform mucus. Pustules and resulting crusts of the lips and the 
nose in female children are often eezematoid features due to the picking 
and scratching caused by lice upon the scalp. 

Treatment. — In male patients the pipe, the cigarette, and the cigar, 
as well as the tobacco chewed and expectorated, may aggravate the 
malady. In all cases it is obstinate and calls for either emollient, 
stimulant, or protective applications. In eczema of the lips displaying 
acute and painful symptoms, frequent fomentations of the part with 
soft rags dipped in hot mucilaginous and alkaline waters will aid in 
controlling the swelling and in alleviating the pain. After such bathing 
some soothing ointment should be applied. In chronic cases, in which 
stimulation is demanded, this can be effected at the time of dressing, 
the parts being subsequently protected by collodion or other material. 
Phenol and silver nitrate are often needed for such dressing. 

Equal parts of tincture of benzoin, alcohol, and glycerin applied 
frequently during the day supply an excellent combination for the ver- 
milion border. For protecting this portion of the lip cold-cream or 
other simple salve, to which has been added enough white 4 wax to make 
as still' an ointment as can be spread with the finger, is recommended. 
A drachm (4.) of the compound tincture of benzoin, with 5 to 20 
(0.33 1 .33) grains of tannin, may often be added to such ointment with 
good results. 

Eczema of the Nostrils ( Eczema Narium) is naturally often asso- 
ciated with a chronic coryza. Inasmuch as one of the common symp- 
toms of hereditary syphilis is "the snuffles," the physician should 



240 HYPEREMIAS AND INFLAMMATIONS 

carefully exclude the possibility of such disorder in every instance 
when an infant with coryza exhibits an "eczema" of the nares or of 
the lips. The age of the patient, an inspection of its anal region 
(which should never be omitted in infantile eczema), and the history 
of the case will throw considerable light upon this important 
question. 

Whether occurring in the adolescent or the child, the disease may 
linger only upon the alee in the pustular or the squamous form, or may 
block the nares with crusts. In infants this obstruction enforces 
mouth-breathing, and the grasp of the nipple by the lips is thus 
interrupted either by respiratory acts or cries of agitation. The 
Schneiderian membrane participates in the inflammatory process and 
pours out its secretion upon the eczeniatoiis skin. This membrane 
when inspected i- seen to be either raw and succulent, or in a condition 
analogous t<» that seen in pharyngitis sicca; that is, dry, glazed, and 
free from discharge. The nostrils are often thickened in consequence 
of infiltration, or are fissured, especially at the lines of the nares, later- 
ally and interiorly. In severe cases, and when the lips participate in 
this process, the pouting, swollen, and distorted organs suggest the 
snout of the lower animals. Adults, as a result, frequently suffer from 
coccogenous sycosis and furunculosis. 

Treatment. In treating these cases all crusts should be removed 
and the parts carefully protected. Ticking of the nose in children 
should be prevented, if needful by the "straight-jacket. " Pencillings 
with compound tincture of benzoin, iodized phenol, silver nitrate, or 
collodion often prove sen iccable. 

J n softening crusts oil may be freely used. For this purpose the 
warm carbolized oil-spray of the atomizer or a glycerin-lotion answers 
well. After softening and removal of the crusts, a simple ointment 
containing from 5 to 20 grains (0.33-1.33) of boric acid, or from 2 to 10 
(0.133-0.66) grains of ammoniated mercury to the ounce (30.), may 
be used. A weak citrine ointment is often serviceable. When the dis- 
ease extends well up in the nares, Neumann employs bougies made by 
combining 2 grains (0.133) of zinc-oxid with 16 grains (1.06) of cocoa- 
butter. Hardaway recommends equal parts of cold-cream salve and 
glycerol of lead subacetate. 

Eczema of the Ears (Eczema Aurium). — The ears are affected 
with eczema both in infancy and maturer years, rather more often in 
women and children, the disease being limited to the whole or part of 
the organ, or extending backward over the postauricular region, or 
downward over the ramus of the superior maxilla. The eczema may 
be acute or chronic, and commonly originates in seborrheic dermatitis 
(which see) of the scalp or the face, but may find its origin in chronic 
discharges from the external auditory m^tus; in the growth of 
aspergillus in the same canal; in exposure to temperature-changes, 
especially with high winds; in frostbite; in the irritation set up by 
pediculi and by the auricular rim of the frame of spectacles; in the 
toxic effect induced by the hook of cheap ear-rings and by dyed bonnet 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 241 

ribbons; in the traumatism of ear-piercing; and in thehabil of unneee - 
sarily picking the car to relieve it of \\a\ or of trifling sensations of 

irritation. 

Symptoms. The pustular and moist forms arc common at the supe- 
rior, inferior, and posterior boundaries of the pinna, where a linear 

fissure is apt to form in the line of the angle made by the auricle with 
the plane of the adjacent integument. The motions imparted to the 
ear by handling it, or by placing the hat on the head and tying hat- 
strings over the ear, always tend to aggravate the disorder. Long 
hairs worn over the ears have a similar effect, by the production of 
friction and the retention of heat. The lobules may display the 
erythematous and scaly phases of eczema, becoming infiltrated, and 
having a deformed appearance and lurid-red color, the affection pur- 
suing an indolent course. The lobules alone of both ears in young 
women may similarly be affected, and may exhibit these phenomena 
for consecutive years. 

Sometimes the entire auricles are uniformly dark-red, infiltrated, 
alternately weeping and scaling, and project to a noticeable extent 
from the side of the head in consequence of their increase in bulk. The 
itching is usually more annoying than severe, being accompanied by a 
characteristic sensation of tenseness and fullness of the part. Like 
the eczema which occurs at the other mucous outlets of the body, the 
affection in the meatus is particularly obstinate when it assumes a 
chronic form. Symmetry to the extent of involving both ears, though 
commonly to a different degree in each, is rather the rule than the 
exception, and is doubtless due to the simultaneous operation of 
effective causes. 

Diagnosis. — Eczema of the ears is to be distinguished from seborrheic 
dermatitis, dermatitis venenata, and pyogenic infections occurring in 
this region. 

Treatment. — The treatment should at first be soothing and protective 
by the use of zinc-salve or diachylon ointment or by soothing and astrin- 
gent lotions; afterward stimulation may be needed. A firm bandaging 
of the ears to the head may be required to support them, to prevent 
irregular pressure (of the head upon the pillow), and to retain external 
medicaments. In chronic cases stimulating applications are often well 
tolerated, and sulphur, salicylic acid, ichthyol, and tar-ointments here 
play an important part. Treatment appropriate to the otitis externa 
or to the aspergillus may be required. Bulkley recommends an oint- 
ment of 1 drachm (4.) of tannin to the ounce (30.), deeply and 
thoroughly passed into the meatus on a canuTs-hair brush. French 
authors generally advise small tampons smeared with an ointment and 
left in the canal. Burnett employs - drachms (8.) of oil of tar to 1 
ounce (30.) of alcohol. Great benefit is derived from painting the 
indolent surfaces with solutions of silver nitrate. The intractable 
forms almost invariably affect adults, in whom there is usually a 
history of improvement under treatment, followed by relapse, due 
to exposure to wind, heat, cold, or other sources of irritation. Manx 
K> 



242 HYPEREMIAS AND INFLAMMATIONS 

cases require the treatment recommended for dermatitis seborrheica; 
others may require radiotherapy. 

Eczema of the Eyelids (Eczema Palpebrarum). — In eczema of the 
eyelids the free edges of the eyelid, or the skin over the orbital margin 
of the tarsal cartilage, may chiefly be atl'eeted, both in children and 
adults. When the tree edge of the eyelid is involved, there is present 
a species of coccogenous sycosis, the hair-follicles becoming inflamed 
and furnishing a purulent discharge, which may agglutinate the lids. 
The latter are thickened and swollen, become the seat of moderate 
itching, are picked rather than scratched, and exhibit minute crusts 
between, or glued to, the liairs. The disorder is often accompanied by 
a seborrhea of the Meibomian follicles, and is described by oculists 
under the designation of l>/< pkaritis or tinea tarsi. Inasmuch as the 
facial expression is characteristic when the eyelids are thus involved, 
patients exhibiting this form of eczema arc usually set down as 
"scrofulous," though the disorder occurs in many individuals with no 
sign of struma, and eczema surely is not such a sign. 

Fissures occasionally form at the commissure of the eyelids. The 
disorder may complicate eczema of other parts of the face. In ery- 
thematous eczema faciei of adults there is usually swelling, with puffi- 
ness, especially of the lower eyelid. The conjunctiva may or may not 
be implicated. A ehronie granular condition of the eyelids is not noted 
as frequently as might be suggested a priori. 

Diagnosis. In the diagnosis care must be taken to exclude syphilis, 
lupus, and pediculi. Piedra of the eyelashes must not be overlooked. 
Instead of the ordinary nits of the lash, there are in such cases jet- 
black, pinhead-sized masses of ivory-like hardness attached to the hairs. 

Treatment. —The edges of the eyelids should be cleansed carefully 
with a weak alkaline solution and a soft camel's-hair brush whenever 
the eyelid is involved, and then as carefully dried and anointed with 
cold-cream salve. In acute eases the closed eyelids may be bathed 
frequently with warm solutions of boric acid or of borax (1 to 2 drachms 
(4. to S.) to the pint (480.)), and strips of soft lint, soaked in the 
same solution, or in a very dilute glycerin and phenol solution, may be 
laid over the closed lids for as long periods during the day as these 
remedies are comfortably tolerated. In chronic cases red mercuric 
oxid ointment, from 1 grain to 10 (0.066-0.66) to the ounce (30.), 
with or without an equal quantity of salicylic acid, is held in high 
esteem. Opthalmologists, in the treatment of this affection, frequently 
use an ointment of yellow mercuric oxid, 1 to 3 grains (0.066 to 0.2) 
to the drachm (4.). In place of these mercurials the unguentum 
hydrargyri nitratis, 1 part to 6 of cold-cream salve, may be applied, or 
resorcin 1 part to 100 of simple unguent. Epilation of the eyelashes 
may be necessary. Pencillings with solutions of silver nitrate in 
various strengths are also useful in chronic cases, but these solutions 
must carefully be confined to the eyelids, and not be suffered to come 
in contact with the conjunctiva. Excessive use of the eyes must be 
prohibited. 



TOPICAL AND SPECIAL VARIETIES OP ECZEMA _'l:; 

Eczema of the Beard ' Eczema Barbce). Eczema may involve the 
region of the beard only, or it may exisl In connection with the d 

on other parts of the face. 

Symptoms. In recent cases there i- no loss of hair, l>ut in those of 
long standing the hairs are thinned and fail to hide completely the 
reddened surface beneath, covered here and there with pustules or dis- 
playing floors of broken pustules, dried Inflammatory products, yellow- 
ish and greenish scales and crusts. Beneath the crusts the surface 
is smooth, not lumpy, as in hyphogenous sycosis. The hair-follicles 
are not solely involved, as in the coccogenous form of sycosis, but 
evidently they and the integument between them are inflamed. 
In chronic cases the symptoms may be those of erythematous and 
scaling eczema. In recent eczema the hairs are not loosened in their 
follicles, but in chronic cases such loosening does occur, and there is a 
true defluvium capillitii. The disorder is one primarily involving the 
skin, and secondarily the hair-follicles, extending as smoothly over the 
surface as an eczema on the cheek of a woman. There is commonly 
a certain degree of symmetry, to the extent, at least, of involving 
the beard in different degrees on both cheeks at once, or the chin on 
both sides; often the symmetry is perfect. Symmetry is rare in the 
several sycoses of the same part. 

The disease is accompanied by itching, rarely so severe as upon the 
smooth parts of the face, is particularly obstinate, and is extremely 
disfiguring. When extending into the region of the beard from other 
parts, there is usually association with eczema of the ears. When 
limited to the region of the moustache, there may be an eczema of the 
nares and a chronic nasal catarrh or seborrheic dermatitis. 

Diagnosis. — The condition is more superficial than that of hyphog- 
enous sycosis. There are no deep-seated nodules, as in the latter 
disease. From coccogenous sycosis, eczema of the bearded region is 
differentiated with greater difficulty, as the two conditions have many 
features in common. Sycosis is primarily an inflammation of the hair- 
follicles, a distinct folliculitis, and presents a characteristic pustule, 
pierced by a hair, at the mouth of the follicle. In this disease there are 
also found papules and small tubercles. Though there is a superficial 
inflammation of the follicle in eczema of the beard, a distinct folliculitis 
is not present and there are no papules or tubercles. Moreover, the 
skin-surface between the follicles is evenly involved in eczema, while 
it frequently escapes wholly or in part in sycosis. Eczema quite com- 
monly coexists on other portions of the face, and is more apt to be 
accompanied by itching, while sycosis is limited strictly to the region 
of the beard. It must be remembered, however, that an eczema barbae 
is often the forerunner of a genuine coccogenous sycosis. 

Treatment. The treatment of recent cases of eczema of the bearded 
region is that of similar phases of the disease on other part ^ of the body, 
l>\ mean- of the simpler lotions and ointments; but cases of long stand- 
ing are exceedingly stubborn and frequently require vigorous meas- 
ures. After removing crusts and other accumulations by soaking with 



244 HYPEREMIAS AND INFLAMMATIONS 

oil and thorough washing with soap and water, the heard must be wholly 
removed. Clipping short the hairs of the face will not answer, though 
this is generally preferred by the patient, as exposing to a less degree 
the unsightly surfaee beneath. Nothing short of epilation or of shav- 
ing, and repeated shaving every second day, will effect the desired 
result in chronic cases. As soon as the disease is reduced practically 
to an eczema of the non-hairy parts, it improves in proportion to its 
distance 4 from the mucous outlets of the body. When limited to the 
bearded cheeks, the most obstinate cases in the course of a single month 
may he robbed of one-half their unsightliness. The patient should be 
encouraged by reminding him that usually it is but the first step which 
costs, each succeeding removal of the heard being accomplished with 
greater comfort to himself physically and mentally. After each shav- 
ing the skin should be bathed with water as hot as tolerable, and, if at 
night, a lotion or an ointment, or the latter after the former, may be 
used. The salves most useful for this purpose are sulphur, 10 to 60 
grains to the ounce (0.66 I. to 30.); diachylon ointment with salicylic 
acid, o to 10 grains to the ounce (0.33 0.66 to 30.); and zino or tar- 
ointment, ban-ly the surface requires painting with weak solutions of 
silver nitrate. As the condition improves a dusting-powder will afford 
needed protection during the day. The shaving should be continued 
for months after the disease is at an end. 

Eczema of the Genital Organs (Eczema Geniialium) is remarkable 
for the severity of the subjective sensations it occasions; for its tend- 
ency to persistence, recrudescence, and nocturnal exacerbation; and 
for the liability to the production of the sexual orgasm by the act of 
scratching. In men the surfaces most often involved are the anterior, 
posterior or lateral faces of the scrotum where they meet the thigh, 
though the surface of the penis, as also that of the pubes and the peri- 
neum, may be involved. In women the labia majora, more rarely 
the labia minora and vestibule of the vagina, are affected, with occa- 
sionally extension of the disease to the same contiguous parts as in 
men. 

Eczema thus located is, as a French writer has well said, "a dry 
disease in a moist locality." Vesicular and pustular forms are much 
rarer than the erythematous, the papular, the papulo-squamous, and 
the erythemato-squamous. In women the moister forms are more 
frequent, doubtless because of the wider mucous outlet and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, edematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most of 
the severe cases. An eczema intertrigo at the labio-femoral angle is 
common. Over the whole may be poured the normal or patholog- 
ically altered secretions from uterus or vagina. The disease, however, 
is sufficiently common after the menopause, when there is usually 
physiological atrophy of the uterus. 

Symptoms. — The typical disease in men is recognized in the thick- 
ened, reddened, perhaps slightly scaling, integument of the scrotum, 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 245 

which may also be fissured, excoriated by the finger-nails, or <•<• i red 
with blood-crusts. Torn papules, even tubercles and nodose swelling , 
may be closely packed together, exhibiting a lurid or even purplish hue. 
In aggravated cast's the infiltration is so greal as to deform the parts, 
increasing the thickness and deepening the normal furrows of the 
scrotal integument to the grade of many times its normal condition, 
producing thus an elephantiasic appearance. In eczema of the penis, 
also, the prominent symptoms are edema, itching, and redness, with 
slight scaliness. 

In both sexes, as before indicated, attempts on the part of the suf- 
ferer to relieve the itching are often as severe and prolonged as they 
are ingenious. Commonly no relief is obtained until a serous sweating 
or weeping of the thickened tissues is induced by the friction. Inas- 
much as the latter in severe cases is frequently repeated, the physical 
dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that eases of long standing are often 
registered by the physician. Though unconnected with venereal dis- 
ease of any kind, there is for many a special dread of an eczema of these 
parts, simply because of its location. With sleep disturbed, the mind 
agitated, and the nervous system teased by an intolerable itching, 
one can scarcely wonder at the eloquence with which many patients 
describe their sufferings. It is a disease of middle life and of advanced 
years. It is rare to see a well-marked, obstinate case in a child. 

Etiology. — The causes, exciting and aggravating, of eczema of the 
genital region are often obscure, but undoubtedly depend largely upon 
heat, moisture, and friction. These factors are favored, first, by the 
effect of gravity, the organs in question being situated, when the body 
is in the erect position, at the inferior apex of the double cone form- 
ing the trunk, and being thus subject to the force of gravity; second, 
by the arrangement of the clothing in both sexes, by which heat and 
friction-effects are heightened; third, by uncleanliness, the secretions 
and discharges from the adjacent mucous tracts being suffered to 
accumulate upon the person. The cause may lie in some disturbance 
of the genital organs or of the nervous system. 

In many eczemas of the surface, and especially those of the genital 
region, the urine will be found to contain albumin or sugar, and these 
conditions have been supposed to lie at the root of the eczema. Aside 
from the fact that the presence of these substances in the urine points 
usually to constitutional abnormalities, which in themselves might pre- 
dispose the skin to eczematous attacks, it may be said of sugar that it 
[s,perse,si profound irritant to the skin and mucous membranes. Any 
part moistened constantly or intermittently with saccharine urine will 
respond eventually with an outburst of eczema. Sugar and albumin 
are known, however, to be producible in urine by external irritants, 
among which are cutaneous diseases. If a patient with saccharine 
urine and severe genital eczema be kept in bed in the recumbenl posi- 



246 HYPEREMIAS AND INFLAMMATIONS 

tion for a few days, while any soothing application productive of coin- 
fort is continuously applied to the tender and excoriated surface, the 
sugar may rapidly disappear from the urine. Many eases of extensive 
and severe eczema of the genital region in both sexes occur in patients 
in whom careful and repeated examination of the urine fails to reveal 
sugar, hut this examination should he made in every case. Genital 
eczema occurring with glycosuria is one of a group of disorders named 
by French authors Diabitides Genitales, 

Diagnosis. The diagnosis of eczema of the genital organs is between 
ringworm, acne, pruritus, scabies, pediculosis, the venereal disorders, 
and herpes progenitalis. The first-named affection may occur alone 
or may induce or may he grafted upon the eczema. Ringworm may he 
recognized by t he discovery of the fungus, and is clinically distinguished 
by the crescentic edge of the spreading patch, its convex border looking 
away from the genital centre 1 . 'Flu 1 "follicular vulvitis" of gynecological 
authors i- a genital acne and is manifestly limited to the glands and 
the periglandular tissues. The same is true of bromin and iodin 
acne, which may he developed in the same situation in both sexes. 
Genital pruritus may beget an eczema from scratching, but it is accom- 
panied primarily by do skin-lesion. The pruritic, papular lesions of 
scabies upon the male genitalia are always associated with typical 
manifestations elsewhere on the body. The pubic louse is visible to 
the eye, as are also it> reddish excreta and nits. The ulcers and sclerosis 
of chancroid and primary syphilis are rarely accompanied by itching, 
and, though occasionally multiple, never exhibit diffuse patches of 
disease. Syphilodermata are recognizable by their characteristic 
features and the history of an infectious disease. In herpes progenitalis 
there are precedent burning, smarting, or neuralgic sensations, the 
occurrence of vesicles or groups of vesicles (lesions rare in eczema of 
the genitals), and frequent limitation of the disorder to the mucous 
surfaces or to the muco-cutaneous lip by which such surfaces are 
bounded. In eczema these boundaries are usually respected and the 
disease is much more strictly cutaneous. 

Treatment. — The treatment is to be conducted on the general prin- 
ciples heretofore outlined. Careful attention should be directed to 
the diet and the habits of living. In diabetic eases every effort should 
be made to remove or reduce the sugar present in the urine by an 
appropriate regimen. Sponging of the genital region with alkaline 
water as hot as can well be tolerated, followed by the blander lotions, 
oils, and ointments at night, and the use of antipruritic dusting-powders 
in the daytime, must not be omitted. In eczema of the scrotum a 
suspensory bandage lined with lint, which is wet with a lotion, smeared 
wdth an ointment, or thoroughly covered with a powder, can usually 
be employed with advantage. The habit of scratching must be broken 
up at all hazards. In chronic cases treatment by soft soap and diachylon 
ointment will be found useful. Caustics, solutions of mercuric chlorid 
and other mercurials, phenol, and especially the tarry compounds, are 
often necessary. The Lassar paste also may be used with advantage. 



TOPICAL iND SPECIAL VARIETIES OF ECZEMA 24* 

In some persistent cases, with decided infiltration, radiotherapy has 
given prompt, relief. 

The following formulae are useful in allaying the irritation of some 
acute and subacute eases: 

120 
8 
8 

120 



li- 


Liniment . calcis, 


I7>iv; 




Zinci oxid., 
( rlycerini, 
Liq. calcis, 


r,..i; 
P5ij; 

fgiv; 


Sig 


. — Lotion to be applied at 


night after bat 


3- 


—Liniment, calcis, 
Acid, hydrocyanic, dil., 
Liq. plumbi subacetat., 
Glycerini, 
Aq. ros., 


fgiv; 

i"5.i; 
f 5 • j ; 
foij; 
ad f o viij ; 



M. 



120 
4 

8 

8 

240 



M. 



Sig. — Cream, for application on strips of old linen. 



Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated 
by intertrigo, the latter condition requires special relief by the inter- 
position of soft lint spread with an ointment. 

Eczema of the Anus and Anal Region (Eczema Ani), in its etiology 
and characteristics, is closely allied to the same disease in the genital 
region. The presence of ascarides and hemorrhoids occasionally in- 
duces or aggravates the disorder; though this complication is rarer 
than is commonly supposed. Multitudes of men and women who 
suffer from piles never complain of eczema. The eczema may occur 
in erythematous, squamous, or papular form, in the order named; thus 
exhibiting here, as on the genitals, "a dry disease in a moist locality." 

The redness, infiltration, and itching may be limited to the verge of 
the anus, radiate from the latter in stellate lines, creep upward between 
the nates in the cleft, sweep forward over the perineum to the genital 
region, or extend laterally, with intermediate intertrigo, over the inner 
face of each thigh. Rarely the buttocks are covered with the same 
lesions. Fissures and excoriations are apt to appear about the anal 
orifice. 

This disease is common in infancy, when want of attention to the 
removal of the napkin is a fertile source of mischief; and also in per- 
sons in middle life and in advanced years, when it becomes particu- 
larly intractable. The itching is intense in the latter class, with fre- 
quent nocturnal exacerbation. Unfortunately, the scratching is often 
reflex, and is practised during sleep, from which the patients are 
often aroused by their manipulations. Pollutions, fully recognized or 
occurring during profound sleep, or, more usually, in states of semi- 
consciousness, complicate certain cases; defecation becomes painful; 
the harassed nervous system of the sufferer is often in a deplorably 
wretched condition. In cases of long standing the usual congested, 
thickened, infiltrated, and almost elephantiasic appearance of the skin 
is presented, with occasional fissures and exaggeration of the natural 



248 HYPEREMIAS AND INFLAMMATIONS 

furrows. The part may simulate in aspect the formidable conditions 
discovered in passive pederasty. 

Treatment. — In the treatment of these cases the use of very hot water 
by sponging, and the subsequent application of ointments, in some 
cases mild but in others stimulating, have yielded the best results. 
In the case of infants dusting-powders and the blander ointments are 
alone to he employed ; in adults, especially in chronic cases, tar in some 
form is especially valuable. Here the Lassar paste may be applied, 
or tincture of tar he freely painted over the surface; or there may be 
used one of the tarn ointments, such as the Wilkinson salve, of suffi- 
cient firmness to retain its form as an unguenl when subjected to the 
heat of the part. Caustics, especially the silver nitrate in crayon, are 
useful when there arc fissures and excoriations. Corrosive sublimate, 
5 to \ of a grain (0.016 0.03:5) to 1 ounces (120.) of milk of almonds; 
Squire's glycerole of plumbic subacetate, \ drachm (2.) in 2 ounces 
(60.) of glycerin and water; or, as a substitute for the latter, soft-soap 
and diachylon plaster, are here of special service. Almond-oil, or an 
ointment containing 2 to K> per cent, of phenol, often gives relief. 
DuliriiiLr recommends the following: 



\\ Sulphur, pracipitat .. 


i )ij: 


2 


66 


Naphtol., 


;-).i: 


I 


33 


Moipli. acet ., 


gr. ij; 




133 


Zinci call).. 


3i; 


4 




Ungt. aq. m*., 


5j; 


30 


IV 



When defecation is painful, the stools should he semiliquid in order 
to insure non-aggravation of the local disorder; not, it need scarcely 
he remarked, with a view to eliminating any materies morbi by purga- 
tion. Small tampons of cotton may he smeared with an emollient 
ointment and gently inserted for a short distance within the anus. 
Tincture of benzoin, 1 part to S of vaselin, may be used in this 
manner. Kaposi recommends cocoa-butter suppositories, containing 
zinc-oxid with belladonna or opium. When complicated by true 
fissure of the anus, the sphincter ani must be stretched or divided, or 
dilated with medicated bougies. At night a cataplasm is applied. 
The parts are washed frequently with tepid water, and the anal tam- 
pons are smeared with cocaine. During the day zinc-oxid salve, 30 
grains (2.) to the ounce (30.) of vaselin, is applied, and over this are 
thoroughly sprinkled equal parts of zinc-oxid and bismuth-subnitrate 
in fine powder. Collodion medicated with 1 to 3 per cent, of salicylic 
acid, and lotions containing 1 scruple (1.33) of silver nitrate to the 
ounce (30.), are of great value in many cases. Besnier recommends 
the use of a clyster after each bowel-movement, the fluid being retained 
for only a short time. 

Veiel prefers the cautious use of chrysarobin- to tar, employing the 
latter either in the form of spirits or as tar-diachylon, 1 part to 20, 
gradually increasing in strength. Phenol, 1 to 5 per cent., and glycerin, 
2 to 10 per cent., in elder-flower water or in almond-emulsion, are 



TOPICAL AND SPECIAL VARIETIES OP ECZEMA 249 

specially indicated in fleshy women when the disorder, as is often the 
case, is complicated with intertrigo. 
The key to most cases of anal eczema is to be sought in the dietary. 

This disorder, in adults particularly, is likely to be a significant symp- 
tom of gout, and without the dietetic medicinal treatment of thai con- 
dition no local applications avail. Tobacco and alcohol are invariably 
to l)e excluded in the case of patients of this class; and blue pill, alkalies, 
colchicum, and salicylates are often needed. It is in these manifesta- 
tions of eczema that health-resorts furnish their best results, necessitat- 
ing and inviting, as they often do, an out-door life, an appropriate 
regimen, and an avoidance of stimulants. Even in children and 
infants, when there are no asearides in the rectum or the vulva, the 
dietetic management of the patient should never be neglected. 

Eczema of the Nipple and Breast of Women {Eczema Mammae) — 
Eczema of the mammary region is common in nursing-women, either 
from the irritation produced by the mouth of the infant, or, more 
commonly, in consequence of galactorrhea. Eczema intertrigo is 
common below and between the breasts. The eczema here is vesic- 
ular, erythematous, or squamous in type, with fissures at the apex, 
the side, or the base of the nipple. The serous ooze from the infil- 
trated areas dries as usual into light-colored crusts. There are the 
characteristic burning and itching. The disease may occur on one 
or both breasts, and, especially with a galactorrhea in the summer, 
may spread extensively, covering both breasts, the surface of the 
abdomen, and the intermammary region. The circumscribed forms 
occur also in pregnant or in unmarried women, and are to be distin- 
guished from scabies, which in women is prone to occur upon the 
breast. 

Paget 's Disease, which in its early stages presents all the appear- 
ances of an eczema, is more fully described in this treatise among the 
epitheliomata ; it is sufficient here to call attention to the important fact 
that a fairly well-defined eczematoid patch, surrounding the areola of 
the nipple or that organ only, with infiltration, itching, and possibly a 
fissure of the nipple, or a crust covering a superficial erosion, may be 
the sign of an epitheliomatous change already advanced either in the 
affected part only or deeper in the galactiferous ducts of the breast 
itself. 

Treatment. — The treatment of mammary eczema is that of eczema 
in general. In severe cases of galactorrhea nothing short of weaning 
the child and a cessation of all demands upon the breast will insure 
relief. Every effort should be made in milder cases to avoid this dernier 
ressort. The nipple should be thoroughly cleansed after each nursing. 
As a rule, hot water and soap may be used for the purpose without 
harm and usually with benefit. Any fissure existing should be then 
painted with compound tincture of benzoin, tincture of myrrh con- 
taining 1 grain of mercuric chlorid to each ounce (().()('> to 30.) or weak 
solutions (2 15 per cent.) of silver nitrate. The whole should imme- 
diately be covered with a protective ointment or paste. The zinc- 



250 HYPEREMIAS AND INFLAMMATIONS 

oxid or diachylon ointment spread on lint serves the purpose well. 
Salicylated and borated pastes are sometimes preferable. Lister's 
salve often does well: 

1$ — Acid, boracic. subtil, pulv., 

Cerae alb., aa gr. w; aa 1 

Paraffin, 

01. amygdal., aa 5ss; aa 2 M. 

In some instances stronger and more stimulating remedies are neces- 
sary. Before the child takes the breast all but the simplest preparations 
should be entirely removed with oil or other unirritating agent. 

Fournier recommend- a breast-plate of caoutchouc. When the dis- 
ease is limited to the nipple and areola in nursing-women, the glass 
and rubber apparatus sold in the shops may be tried in the hope of 
saving the nipple from month-contacts in nursing. Sometimes they 
answer admirably; often they utterly fail. Dusting-powders are valu- 
able in mild cases and for any intertrigo that may exist between and 
beneath the breasl S. 

Eczema of the Umbilicus {Eczema Umbilici). — Generally in these 
casts a reddish and infiltrated, more or less annular, patch surrounds 
the umbilical depression, which may be filled with crusts. In most 
cases it is either induced or is aggravated by a seborrhea fluida, which 
gives origin to the peculiarly nauseating odor characteristic of the 
disease. Syphilodcrmata, pediculosis, and scabies in women are to 
be carefully excluded in the diagnosis. 

Treatment. Liquor sodas chlorinatse, phenol solutions, and, in 
chronic cast's, iodized phenol, will be required in its management. 
The dressing of the navel in the newborn infant, the improperly ad- 
justed apparatus for retention of an umbilical hernia, and the corsets 
or "uterine supporters" of women, should not be permitted to occasion 
or aggravate the disease. 

Eczema Crurum {Eczema Crurale). — Upon the legs, where the force 
of gravity is more potent than in other parts of the body, aggravated 
forms of eczema are found complicated with varicose veins and edema, 
with dense infiltrations and indurations. In ancient cases the frequent 
elephantiasic aspect is significant, one limb being occasionally several 
inches larger in circumference than its fellow. The skin is covered from 
knee to ankle with enormous patches of eczema rubrum of an intensely 
angry appearance, moist and crust-covered; is dry, glazed, and of a 
lurid, reddish hue; or is dry, horny, and ridged with irregular projec- 
tions surmounted by scales resembling the rough bark of a tree; or, 
again, with or without edema, the integument is tense, inelastic, seamed 
with scars of old varicose ulcers, and deeply and irregularly pigmented, 
a condition with some difficulty distinguished from syphilitic ulcer- 
ation of the same region. At its onset eczema of these parts may 
assume any one of its knowm forms. In infants in long clothing, where 
the lower extremities are subjected to a higher temperature than in 
adults, the vesicular and pustular forms are common. The exceed- 



TOPICAL AND SPECIAL VARIETIES Oh ECZEMA 251 

ingly obstinate forms of eczema of the legs, especially those compli- 
cated with varicose veins, arc, of course, chiefly encountered in middle 
life and in advanced years. 

Diagnosis. The diagnosis is, in general, to be established by con- 
sidering the points heretofore discussed. The chief difficulty lies in 
distinguishing the eczema associated with ancient varicose cicatrices 
of the leg from syphilitic scars of the same locality that have resulted 
from degenerating tubercular syphilodermata or from gummata. In 
some cases, when no distinct history can be obtained, there will be a 
doubt, since the force of gravity upon the vessels, even without vari- 
cosities, produces certain common features, notably deep pigmenta- 
tion, in both classes of cases. In women the sexual history is all- 
important, including the order of succession of abortions, miscarriages, 

Fig. 50 




Eczema of the Legs with verrucous lesions. 



and viable infants. In both sexes the discovery of other lesions, and 
especially of characteristic cicatrices elsewhere, must be attempted. 
It will be remembered that the syphilitic ulcer tends to the shape of 
a circle or a segment of a circle, and, though occasionally existing as 
the sole lesion upon one leg, it is frequently multiple, or may involve 
both extremities, the pigmentation in old cases occurring chiefly at the 
periphery of the scar. Very extensive pigmentation about ancient 
cicatrices, especially disposed between irregularly defined scars, is 
commoner in eczematous forms, as the pigmentation due to syphilis, 
though long-lived, is yet the more ephemeral. With periosteal nodes 
the diagnosis is clear. 

Treatment. The treatment of eczema of the 4 legs docs not differ 
from that of eczema in general, except as regards the indications to be 



252 HYPEREMIAS AND INFLAMMATIONS 

met relative to the support of the parts, thus counteracting the effect 
of gravity. In severe cases rest with the foot elevated and the leg 
placed in the horizontal position should be maintained, and other indi- 
cations met by the use of the various liniments, lotions, and ointments 
already described. For those who must pursue their accustomed 
occupations the problem is difficult. An excellent preparation for 
subacute and chronic cases is found in the glycogelatins (q. v.), as they 
furnish not only protection, but also some support. Moreover, they 
frequently may be left in position for a week at a time. As a rule, 
they are not indicated in acute cases or where there is much discharge; 
yet in some of these eases they are well tolerated and do good. From 
1 to 3 per cent, of ichthyol, thiol, or salicylic acid in most cases may be 
added to the glycogelatin with advantage. 

A dressing well adapted to the larger number of cases of eczema of 
the lower I in il»- consists in disinfection of the surf ace and the application 
of the Lassar paste or other well-selected unguent or paste, followed by 
dustingthe whole area with a powder, over which may be neatly applied, 
if desirable, a cheesecloth bandage. Often, how ewer, this bandage may 
be dispensed with, as in both -exes a woman's long stocking, made 
light and thin, such as is used in the summer season, and always of white 
or undyed cotton, may be drawn over the limb, Over this stocking 
may be wound, for the purpose of support, either a flannel bandage 
cut on the bias, which can, as a rule, be applied without special skill 
by the inexpert, or, in chronic cases thai will tolerate it, an elastic band- 
age, the inner white stocking being changed with each dressing. In 
the case of male patients it is often desirable that the man's sock 
be drawn over the long white stocking below. In this way support 
without compression (which is the essential point) may be secured. 

A favorite dressing in dry, papular, erythematous, and squamous 
patches of the disease is applied as follows: The parts are bathed with 
borated water for several minutes until the itching is relieved, and then 
are carefully and thoroughly dried. The patch is then completely 
covered with a dusting-powder, which, according to the indications 
of the case, is either emollient, astringent, or stimulating. Finely 
powdered tannin with French chalk, or boric acid and starch, or bis- 
muth subnitrate, zinc, and starch may thus be used. Strips of cheese- 
cloth are superimposed. A snug-fitting rubber or flannel bandage cut 
on the bias encompasses the whole. The dressing is left in situ as long 
as it is comfortable, often for two or three days, when it can be removed. 
In properly selected cases the itching is relieved, the infiltration is 
reduced, and the patch soon loses its hyperemic aspect. Occasionally 
no other treatment will be required. 

Eczema of the Hands and the Feet (Eczema M annum, Eczema 
Pedum). — Eczema of the hands frequently arises from irritation 
induced by substances employed in the various trades and professions. 
On both the hands and feet it may be induced by a ringworm fungus 
(see chapter on Trichophytosis). Owing to the inability of most 
patients to give up their work, the management of the disease in these 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 253 

situations is rendered more difficult. A broken-down transverse arch 
of the foot is cited by Ruggles 1 as a cause of eczema in this region. All 
forms of eczema arc here seen erythematous, vesicular, papular, pus- 
tular, and squamous involving the entire surface, or limited to the 
wrists, ankles, Interdigital spaces, palmar or plantar surfaces, or one 
or more digits of either hand or foot. The motions of the pari arc so 
free that fissures are common and often are exceedingly painful. The 
itching may he severe, and parts of one hand or of one foot may be 
extensively rubbed, torn, or abraded by the other. Vesicles are fre- 
quently encountered upon delicate portions of the skin, as upon the 
dorsum and interdigital spaces, while in the denser palm and sole such 
lesions are deep seated and do not tend to spontaneous rupture, but 
on puncture a clear serous or a cloudy fluid may be evacuated. 

Fig. 51 




Eczema fissum. (Fox.) 

Palmar and Plantar Eczema is commonly asymmetrical, but may be 
symmetrical. The hands are more often involved than the feet. The 
condition is characterized by the appearance of irregular, ill-defined, 
more or less diffuse areas of dry, dead-whitish, or hyperemic, indurated, 
and thickened integument, which may be fissured or which may pro- 
duce such a tense inelasticity of the surface that the digits are 
semiflexed into the palm or sole. 

Circumscribed patches of eczema, with fairly well-defined outline, 
reddish in color beneath crust or scale, subacute in course, and accom- 
panied by paroxysmal itching, are of common occurrence on the dor- 
sum and also on the palm or the sole. Tn the latter situation they 
may be traversed by one or more painful fissures, the same being true 
of the fingers and the toes. Upon the back of the hand these circum- 
scribed patches arc prone to pursue an indolent course, improving 
temporarily under appropriate treatment and becoming aggravated 
by every exposure to the causes by which they were first induced. 



Jour. Cut. Dis., 1909, xxvii, pp. 105 HI, 



254 



HYPEREMIAS AND INFLAMMATIONS 



The long list of etiological factors which may here he efficient can 
scarcely be enumerated. The majority have already beeB considered 
in discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions, as well as 
the action of toxicants and dyes, must he remembered. Thus, printers, 
bakers, and masons suffer in the hands, and the wearers of dyed stock- 
ings and coarse, ill-fitting shoes and boots suffer in the feet. These 
so-called trade eczemas are often due wholly to local causes and dis- 
appear promptly on removal of the latter. Such conditions should 
properly be classed under chronic dermatitis. 



Fig. 52 




Eczema orhiculare. (Howard Fox.) 



Diagnosis. — In the matter of diagnosis, scabies, dysidrosis, psoriasis, 
and syphilis have to be considered. In scabies the vesicles are firmer, 
more often unruptured, are fewer, more isolated, and more inter- 
mingled with crusts, pustules, and even with bulke, which latter are 
rare in eczema. The discovery of the parasite or its burrows and a 
history of contagion will aid in removing doubt. Numerous pustular 
lesions in young subjects are, however, more commonly produced by 
the acarus. The occurrence of the eruption on the body elsewhere 
than on the hand is also to be expected in scabies, with respect to which 
it should be remembered that the burrow T may not be visible, and that 
it may be wanting w T hen the parasites are present. In dysidrosis there 
is usually a history of hyperidrosis of the hands and feet. The lesions, 
which are vesicular at first, becoming pustular later, are usually larger, 
more deeply seated, and less numerous than in eczema; they appear 
in greatest numbers upon the digits, in many instances not involving 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA 255 

the palms or soles; arc less inflammatory and produce a <ii .ition of 

burning mi her than itching. Exfoliation in dysidrosis leaves a tender 

epidermis rather than an infiltrated, oozing surface. Psoria i of the 
palms and soles is almost always accompanied by the presence in o1 her 
parts of the body of patches, the typical character of which should 
throw light on the local disorder. They are dry, non-discharging 

lesions, very rarely fissured as in eczema of the hands, have a distinct 
contour (which is rare in eczema), and are covered with more abundant 
and more lustrous scales. Eczema is less sharply outlined, and occurs 
in larger and more diffuse areas than either psoriasis or syphilis. The 
sealing- syphilodermata of the palms and soles occur early and late in 
the disease, and usually after a distinct history of infection. The 
lesions in syphilis are usually isolated, firm, deep infiltrations, circu- 
lar in outline, with very sharp definition, and they may be covered 
with dry, adherent, dirty-white scales, beneath which the brown-and- 
red hue of the persistent lesion can be discovered. Superficial or deep 
circular excavations of tissue, single or multiple, with punched or ragged 
edges, are visible. The eruption is rarely, like eczema, accompanied 
by itching or by discharge, but painful fissures may form. It occa- 
sionally affects the dorsum of the hand or the foot, favorite sites of 
eczema manuum, but almost invariably it has in such cases swept 
thither from the palm or from the sole. 

In both syphilis and eczema of the hand, unless the patient be left- 
handed, the right hand is usually more involved, even when there is 
apparent symmetry of distribution of lesions. 

Treatment. — The treatment demands, first, rest for the extremities 
and a simultaneous discontinuance of the exciting cause. In the trades 
the result of the latter can usually be demonstrated by the patient, who 
notices the improvement in the condition of the skin on Monday morn- 
ing after a Sunday's rest. When practicable, protection during labor 
must be secured by the use of gloves, neatly applied finger-cots, rubber- 
stalls, or bandages retaining a dressing on the part of the hand or the 
foot that is the seat of the disease. For circumscribed, non-discharg- 
ing patches on the dorsum of the hand or the foot, the dressing de- 
scribed in connection with eczema of the extremities may be applied. 
When the nature of the labor performed is such as to render it impos- 
sible to secure protection of the hands or fingers in this way, some- 
thing may be accomplished in a few eases by directing that the hand 
be frequently dipped in a protective solution or powdered during the 
hours of labor. Thus, printers may dust their fingers with lycopodium, 
and individuals compelled to retain their hands in irritating solutions 
can anoint these members occasionally with an oily or fatty substance. 
Generally, it may be said that eczematous hands are too frequently 
brought in contact with water; the ill effects of this are made evident 
not only in laundresses, but also in those who personally must attend 
to the ordinary duties of the household. For cleansing the hands oat- 
meal water may be used and after each washing they should imme- 
diately be covered with a suitable dressing, or with a simple lotion, 



256 HYPEREMIAS AND INFLAMMATIONS 

ointment, or powder. For protection of the hands and for the reten- 
tion of dressings the cheap white cotton gloves, such as are worn by 
infantrymen, are convenient and serviceable. They should be large 
enough to go on over the dressings easily and should be washed as soon 
as soiled. For mild cases equal parts of tincture of benzoin, glycerin, 
and alcohol, diluted more or less with water, make a serviceable and 
agreeable application. When extensively and acutely involved, the 
hand should be dressed with care, each finger being separately wrapped 
in gauze which has been soaked in a lotion or oil or has been spread 
with the selected ointment or paste, and the whole covered with a 
bandage or other dressing. 

The local application must be chosen in accordance with the prin- 
ciples previously given for the treatment of eczema in general. In 
subacute and chronic types tarry compounds are very useful, and 
caustics more than ever needful when there are fissures. The fissures 
may often with advantage be painted with compound tincture of ben- 
zoin. Protective flexile collodion plays an admirable part about the 
finger-nails, where irritable seams and fissures form, with over-hanging 
fringes of torn and ragged epidermis, bordered with red. In painful 
eczemas of this region the immersion, particularly at night, of the 
entire hand or foot in hot borated water may be practised, followed 
by careful drying and dressing with the selected applications. 

When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, with the aid of 
hot water, followed by a salicylated soap-plaster or by a salve contain- 
ing ammoniated mercury, 10 to 20 grains to the ounce (0.66-1.33 to 
30. ), or some preparation of tar. For intractable cases caustic potash, 
in the strength of 20 to 30 per cent, solutions, can be mopped well into 
the thickened palm and be followed by a salve application. Crocker 
suggests the application of dressings moistened with a solution of 
pancreatin or papain to the areas of thickened epidermis, the purpose 
being to soften the cells by digestion. 

A paste useful in many mild cases and one which dries rapidly is 
made of 10 parts each of glycerin, dextrin, and water. To this may 
be added from 1 to 3 per cent, of thiol or ichthyol. The ingredients are 
mixed on a hot water-bath and form a sort of liniment, w T hich may be 
painted on the skin. Unna's litharge-glycerin-starch paste, described 
on a preceding page, is also a valuable and effective preparation for 
subacute cases. For chronic, sluggish eczema of the palm, Duhring 
recommends an ointment composed of equal parts of mercurous nitrate, 
plumbic acetate, and zinc-oxid ointments. 

Radiotherapy has given excellent results in a number of these cases, 
the technique being that employed in the treatment of psoriasis. 

For the fingers and hands Unna's mull-plasters (but only if freshly 
imported) fill every requirement. These plasters may be cut into 
strips and be applied with neatness to every digit. Zinc-oxid, sali- 
cylic acid, tar, and ichthyol mulls are all available for this purpose. 

The condition known as chapping of the hands and face is, properly 



m # 






PLATE III 



Traumatic Dermatitis Consecutive to Pruritus Cutaneous. 



DERMATITIS 257 

speaking, a dermatitis, since ii is usually dependent upon exposure to 
wind and weather and disappears when the cause is removed. It 
sometimes occurs, however, as a condition indistinguishable clinically 
from mild eczema of this region. In those subject to this disorder care 
should be taken through the changeable weather of spring and autumn 
not to expose the skin to cold or wind, especially if the hands have been 
previously immersed in water and are not perfectly dry. In many 
instances the mischief can be prevented by a simple oiling of the skin 
after each washing, or instead of oil equal parts of tincture of benzoin, 
glycerin, and alcohol may he used. This last preparation is not only 
a preventive, but it often affords relief in mild cases. Severer forms 
should be treated as corresponding grades of dermatitis or of eczema. 

Eczema as it Affects the Nails {Eczema Unguium). — For descrip- 
tion of this affection, see the section devoted to Diseases of the Nails. 

Eczema of the Tropics. — Prickly Heat {Eczema Solare, Lichen 
Tropicus, Miliaria Rubra, etc.). — For description of this disorder, see 
the chapter devoted to this topic. 

Universal Eczema. — Patients thus affected should be treated in bed. 
The diet, which is of great importance, should be of unstimulating 
quality; but it is not to be forgotten that in a disease involving the 
entire surface of the body the strength is sooner or later liable to be 
exhausted, and a supporting dietary, even ferruginous tonics, is often 
required. 

DERMATITIS. 

Synonyms. — Ger., Hautentzundung; Fr., Dermatite, Dermite. 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under dermatitis, however, are grouped those inflamma- 
tions only in which the result is plainly due to a direct influence 
exerted upon the skin by thermal, chemical, or mechanical agencies. 
The inflammatory process may involve the superficial or the deep 
portion of the integument, or it may extend to the subcutaneous 
tissues, and even deeper. The symptoms vary with the nature of 
the cause, the extent and degree of its influence, and the circum- 
stances attending its operation. There may be simple hyperemia and 
edema of a few hours' duration, or there may follow papules, vesicles, 
bullae, pustules, and crusts. These lesions may be situated on an 
intensely reddened and much swollen base. In severe cases ulcera- 
tion, gangrene, and extensive scarring may occur. With these phe- 
nomena there may be general symptoms of mild or of severe grade, 
due to the influence exerted by the local process upon the general 
economy. When the exciting cause is of moderate intensity but is 
long continued, there results a chronic dermatitis, in which the skin 
may be more or less thickened and infiltrated, dull-red in color, and 
covered with hue, adherent scales. 

Dermatitis Traumatica. — External violence, varying in character and 
severity, is capable of inducing dermatitis, the symptoms of which 
differ in degree, though their career is, in general, the same. In this 
17 



258 HYPEREMIAS AND INFLAMMATIONS 

list are included the inflammations produced by surgical interference 
with the continuity of the integument; excoriations caused by scratch- 
ing, by friction with garments and other articles injuriously acting 
upon the skin; by the various implements handled in the trades; and 
by the bites or stings of beasts, insects, reptiles, and fishes, when the 
result is traumatic and not toxic in character. These injuries max 
be in the form of contusion, blow, concussion, pressure, puncture, 
incision, or laceration; and the consequences be declared in heat, swell- 
ing, redness and pain ; in itching, burning, stinging, or pricking sensa- 
tions; with subsequent inflammatory symptoms, varying in grade from 
mild and transitory hyperemia and exudation to the severer grades of 
inflammation mentioned in the preceding paragraph. 

Dermatitis Venenata. Dermatitis venenata is an acute inflamma- 
tion of the skin caused by the external application of various sub- 
stances of animal, vegetable, or chemical nature, characterized by red- 
ness and swelling, frequently by vesicles and bulla?, and accompanied 
by sensations of itching, burning, etc, in varying degrees. 

Fig. 53 




Dermatitis venenata. (Fox.) 

Symptoms. Careful observation of a typical case of dermatitis 
venenata soon after the onset of symptoms will disclose the exact sur- 
face of contact, such surface being distinctly outlined by a reddened, 
tolerably well-defined line, within the limitation of which will be seen 
a slightly tumefied, erythematous area, at times displaying closely- 
packed, pinpoint-sized papules, vesicles, or pustules. As the derma- 
titis progresses it is not necessarily limited to the surface with which 
the irritant has come in contact. The inflammation may extend to 
adjacent portions of the skin, or, as a result of absorption and conse- 
quent toxic effects, or of reflex nervous irritation, it may appear on 
distant surfaces of the body. Numerous types of cutaneous lesions — 
macules, pustules, papules, vesicles, bulla?, wheals, scales, crusts — free 
serous and purulent discharges, subcutaneous abscesses, and even gan- 
grene with sloughing, may occur, the result being largely proportioned 
to the character of the agent producing the injury and to the suscep- 
tibility of the individual. 

The eruption produced by the poison-ivy and other varieties of rhus 
is largely an American disease; and from its frequency in the United 



DERMATITIS 



259 



States has attracted a ^wa\ deal of attention. A certain degree of 
susceptibility to the poisonous action of the plan! Is requisite for the 



Pig, 54 





Dermatitis venenata produced by chemicals. 
Fig. 55 




I )ermatitia venenata. ( Fox.) 

production of its effects, as some individuals can handle the leaves 

of the plant with impunity, while others, it is claimed, are affected by 
its exhalations within a circle having a radius of several feet. It is, 



200 



HYPEREMIAS AND INFLAMMATIONS 



however, difficult to demonstrate the truth of the last statement, sus- 
pecting, as one may, that such instances may be cases of contact with 
other than the suspected plant. The parts commonly affected are 

the hands and the regions to which the latter are carried, such as the 
face, the genitals, the arms, the thighs, and the neck; barefoot children 
suffer in the feet and the legs. Usually the symptoms are developed 
in the course of a few hours, and they consist of erythematous patches; 
scanty or profuse vesiculation, with abundant serous weeping after 
rupture of the lesions; swelling, edema, and disfigurement; and intense 
burning and itching sensations. Serious effects are occasionally pro- 

Fig. 56 





Rhus radicans: leaf one-half natural size. (Culbreth.) 



duced. Deeply attached scars may result from subcutaneous abscesses 
of parts greatly swollen. Occasionally, in particularly sensitive skins, 
the eruption spreads from the skin-surface affected "by the poison 
to that where presumably none has been applied. It should be re- 
membered, however, that articles of clothing may for brief periods 
of time furnish sources of further trouble, being worn at the moment 
of contact with the plant, then laid aside, and, the occasion quite for- 
gotten, being subsequently employed. Thus, a pair of undressed-kid 
gloves after lying for two weeks untouched have sufficed to awaken 
the disease. 



DERMATITIS 261 

An important variety of dermatitis venenata is thai produced l>\ 
the primrose I Primula obconica, chiefly), ;i number of examples having 
been seen by the author. Foerster 1 regards primula dermatitis as no1 
uncommon, having seen over forty cases in seven years. Sharpe 2 
recorded examples produced by the Primula farinosa, a variety of the 
plant which grows wild. 

Etiology. Among the sources of dermatitis venenata may be named 
several members of the rhus family (Rhus toxicodendron (poison-ivy) 
and Rhus venenata (poison-sumach)), the nettle, the smartweed (Polyg- 
onum punctatum), cowhage (Mucuna pruriens), several members of 
the primrose family {Primula obconica, Primula sinesis, Primula 
cortusoides, and Primula Sicboldii), most of the strong acids and alka- 
lies, croton-oil, cantharides, mustard, tartar emetic, mezereon, the salts 
of mercury, arnica, turpentine, ether, chloroform, tarry compounds, 
resorcin, many of the dyes, and glass in fine powder or in delicate 
filaments, such as are thrust into the skin when handling certain 
articles of Venetian glassware. A common cause of acute dermatitis 
about the forehead, eyes and face is found in the proprietary hair-dyes 
found on the market. This list might be extended indefinitely, as there 
are few articles which are not capable of producing some irritation of 
the surface of the skin if applied to it with sufficient vigor and for a 
certain period of time; and in some cases it is difficult to decide whether 
the effect is more traumatic than toxic. An almost equally long list 
of substances of animal origin having poisonous effects upon the integu- 
ment might be named, such as decomposed or ammoniacal urine, feces, 
ichorous pus, and pathologically altered secretions from the uterus, 
the eye, ear and nose. 

A few of the more common causes of dermatitis are: the use of soap 
containing an excess of alkali, or even minute particles of bone, for 
laundry, toilet, or other domestic purposes, as also several of the pro- 
prietary articles sold in the shops for similar employment. Stockings 
and other undergarments dyed with anilin, picric acid, chromium, or 
arsenic; the leather lining of the inside of the hat or the cap, and the 
painted toys to which the lips of children are applied, will beget mis- 
chief in the various regions of contact for each. Duhring reports cases 
in which the dyestuff in the lining of shoes penetrated the material of 
stockings in women, and produced dermatitis of the feet or the legs. 

The tincture of arnica, an article much used as a domestic appli- 
cation for contused and incised wounds of a simple character, has pro- 
duced very serious annoyance in some cases. The number of these 
accidents is annually increasing, ("artier 3 reports excessive erysipel- 
atous swelling, a phlyctenular eruption, and submaxillary adenop- 
athy resulting from the external use of arnica. Beauvais reported 
to the Paris Medical Society gangrenous results in one case. Buchner 

1 Jour. Anicr. Med. Issoc, August 20, 1010, p. (ill* (a thorough discussion of the 

clinical features of the disease, with a description of the botanical and chemical char- 
acteristics of the plants). 

' [bid., Deoembet L4, 1012, p. 2148. :i Lyon Med., April 13, 1884. 



262 HYPEREMIAS AND INFLAMMATIONS 

believes this poisonous action to be due to insects (particularly the 
Atherix macidatus) found in the calyx of the arnica-flower. Other 
native plants, a large number of which are enumerated in a valuable 
monograph and supplemental list by J. C. White, 1 are similarly effec- 
tive. Wesener 2 reports that the Malacca bean-tree (Anacardium 
orientale) furnishes a caustic oil, called "cardol," or cardolcum pru- 
riens, that produces, after application to the skin, vesicles and vesico- 
pustules, which contain cardol and terminate by crusting. lie reports 
a generalized eruption, beginning on the face, due to this cause. Metol, 
a substance largely used by amateur photographers, produces in sus- 
ceptible skins ;i marked dermatitis similar to that induced by ivy. 
Several marked examples have been seen by the author. Beevo 8 
and others report similar observations. Bernstein 4 reports nine cases 
of dermatitis produced by dinitroehlorbenzol, a substance used in the 
manufacture of dye-stnll's. Irvine' reports cases of dermatitis pro- 
duced by benetol. MacKee' report-, cases of dermatitis in workers 
in coco-bolo wood. Wihnot Evans 7 reports cases of dermatitis due to 
teak. 

The antiseptic dressings of modern surgery are at times responsible 
for eruptive disorders. Orthoform has produced in a number of 
patients coining under our observation an acute vesicular and bullous 
dermatitis. Brady 8 reports an example of orthoform susceptibility. 
Dubreuilh 9 records cases of gangrene following the local application 
of the drug. Iodoform has produced erythema, vesicles, pustules, and 
wheals. 10 Phenol and corrosh e-sublhnate dressings have had similar 
effects. The prolonged application of weak solutions of phenol is 
followed occasionally by gangrene. 11 Formalin causes vesicular and 
pustular lesions of the fingers in predisposed individuals. Many of 
the articles employed therapeutically by the dermatologist should be 
placed in the same category. Green, 12 of London, reports edema of 
the skin, followed by desquamation, resulting from the application to 
it of the ointment of ammoniated mercury in the strength of 2 drachms 
(8.) to the ounce (.30.). 

Leszinsky reports a case of dermatitis of the face following the use 
of a "triple extract of heliotrope" as a toilet-preparation. 

An exceedingly common source of dermatitis is urine retained upon 
underclothing of adults. A persistent dermatitis of the scrotum, the 
perineum, or the inner faces of the thighs in either sex, always calls 

1 Dermatitis Venenata, Boston, 1887; and Jour. Cut. Dis., 1903, xxi, p. 441. 

2 Deutsche Arch. f. klin. Med., xxxvi, p. 578. 

3 New York Med. Jour., September 12, 1908, p. 506; abstr. Brit. Jour. Derm., 1909, 
xxi, p. 34. 

4 Lancet, April 27, 1912, clxxxii, No. 4626; abstr. Jour. Cut. Dis., 1912, xxx. p. 576. 

5 St. Paul Med. Jour., 1912, xix, p. 624. 

6 Jour. Cut. Dis., 1913, xxxi, p. 582. 7 Brit. Jour. Derm., 1905, xvii, p. 447. 
8 Jour. Amer. Med. Assoc, May 7, 1910. 9 La Presse med., 1901, liii, p. 233. 

10 See paper of R. W. Taylor, read before the New York Academy of Medicine, 1887. 

11 Harrington, Amer. Jour. Med. Sci., 1900, cxix, p. 1 (report of 18 cases and review 
of 118 cases from literature). 

12 Brit. Med. Jour., 1884, i, p. 853. 



DERMATITIS 263 

for examination as to whether a few drops of urine are nol left in con- 
tact with such underclothing after each act of micturition, li tula?, 
urinary incontinence, prostatic disease, "stammering of the bladder/' 
imperfect finish of the coup de piston in men, especially altera gonor- 
rhea and similar troubles, are all to he remembered. 

A number of eases of dermatitis have originated in some parts of the 
Orient from contact with the varnish employed in the finishing of 
lacquered ware. This lacquer is manufactured from a rhus varnish. 
A few instances of such dermatitis have occurred in America from 
handling newly imported articles of this class. 

Diagnosis. — An acute dermatitis appearing suddenly on regions of 
the body readily exposed to toxic agents should always arouse sus- 
picion of dermatitis venenata. A history of contact with some irri- 
tating- substance can usually be obtained. The inflammation in the 
beginning is limited to the areas with which the toxic agent came in 
contact, is often asymmetrical, and has no relation to the general 
health of the patient. The process often reaches the point of greatest 
intensity within a day or two after its first manifestations, and sub- 
sides soon after removal of the cause. 

The peculiar features of ivy-poisoning have been described in a 
monograph on the subject by White, 1 of Boston. According to this 
author, the lateral surfaces of the digits first exhibit the symptoms of 
the eruption, later the dorsal surfaces, and latest the thickened palms. 
The efflorescence also is more irregularly distributed, more uniformly 
vesicular, and the vesicles are less transparent than in eczema. The 
lesions, moreover, are more vesicular and less papular at the outset, 
and, though suggesting papules by their situation in the palm, are in 
that situation readily made to exude serum by puncture with a needle. 

The acute and subacute recurring forms of primrose dermatitis 
resemble closely similar forms of eczema, a fact to be remembered 
when seeking the cause of the latter disorder. 

Treatment. — Internal medication is not required. The local treat- 
ment is that of acute eczema. Black wash (preferably dilute), solu- 
tion of sugar of lead, or oleated lime-water may be employed at first, 
and be followed later by dusting-powders. In several instances under 
our observation a dermatitis due to formalin, and which had resisted 
other treatment for months, yielded readily to radiotherapy. A num- 
ber of other cases due to unrecognized agencies have responded equally 
well to this treatment. 

In ivy-poisoning the application of an alkali, for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch), should evidently be considered solely 
with a view to prophylaxis, as it is difficult to understand how such 
neutralization can control the inflammatory process after its onset. 
An ointment made by incorporating a decoction of the inner bark of 
the American spice-bush ( Benzoin odoriferwm) with cold-cream salve 

1 I). Applcton & ('«»., \rw York, L878, from the March number of NYu York Med. 
■lour, of the same year, 



264 HYPEREMIAS AND INFLAMMATIONS 

affords prompt relief in eases in which it is employed, the difficulty 
lying in securing the bark of the shrub in its young and tender state. 

Many topical remedies have been vaunted as specifies for the relief 
of this disorder, from the brine of a pork-barrel to a decoction of the 
leaves of the plant itself. As the eruption usually subsides when the 
skin is protected and not irritated by the local treatment, it is not diffi- 
cult to explain the result in most cases, though it is possible there is a 
parasitic or toxic clement in the poison. Complete covering of the 
affected area with flexible collodion frequently is effective, and if ap- 
plied to the lesions when they first appear often will abort the disease. 
In later stages care should be taken in opening the vesicles to prevent 
their contents from coining in contact with unaffected areas of the 
skin. After emptying the vesicles with a sterile needle, the involved 
areas may be painted several times with a 50 per cent, solution of ich- 
thyol, and when dry covered with a dusting-powder and light bandage. 
A calamine lotion, such as the following, has been found of value in 
most cases due to rluis poisoning. One-quarter of 1 per cent, of phenol 
may be added, if necessary, to control the itching: 



Pulv. calamin., 




,~)iv; 


15 


Pulv. zinc oxid., 




~)iv; 


15 


( Hycerin., 




5 '.i ; 


8 


Soaii biboral ., 




.~i.i; 


8 


\i|. calcis, 


q. s. ad. 


5 viij ; 


240 



Sodium hyposulphite, 1 drachm (4.) to the ounce (30.), often gives 
good results when applied as described above or as a wet dressing. 
Corrosive sublimate lotions; saturated solution of boric acid; carron 
oil; tincture of iron; bromin, 15 drops (1.) to the ounce (30.) of olive- 
oil (Brown); dilute nitric acid; sodium bicarbonate; saturated solution 
of potassium chlorate; and grindelia robusta, 1 drachm (4.) of the fluid 
extract to S ounces (240.) of water, have each been found useful. 
Foerster 1 recommends the early application of alcohol as efficient in 
primrose dermatitis. 

Prognosis. — While, as a rule, cases of dermatitis venenata recover in 
a reasonable time, recurrences may happen when the cause again be- 
comes operative; and most important is the fact that occasionally a 
dermatitis of this type so sensitizes the skin that other irritants of 
a dissimilar nature may cause a recurrence, until finally a persistent 
eczema results. 

Dermatitis Calorica — Burns. — The action of intense heat from fire, 
hot steam, boiling water, etc., produces injurious effects upon the skin 
of varying grades. 

Rays of heat and heated objects at a temperature from 125° to 175° F. 
produce immediately, or after a brief interval, first, an erythema, 
which disappears when the source of the heat is removed; second, after 
more prolonged exposure, the symptoms of active inflammation and 
exudation. Vesicles or bulla?, isolated or confluent according to the 

1 Loc cit. 



DERMATITIS 265 

severity of the cause, may rise from ;i reddened skin, which is usually 
intensely painful. These lesions arc persistent or are transitory, and 
are generally filled with a clear sen mi, which exudes and dries into crusts 
after rupture of the chamber in which it was imprisoned. At other 
times the exudation is so abundant that the epidermis rises in broad 
plates, from beneath which the serum is exuded. This process may 
terminate by a free production of pus upon the surface and gradual 
resolution. Adenopathy is a frequent concomitant symptom. In 
such dermatitis of extensive areas of the skin, the intensity of the 
process may awaken a violent fever, or death may result from shock 
or exhaustion. 

In yet severer grades there is the production of an eschar, which is 
dry, brown, blackish, and destitute of all signs of vitality; or, as Kaposi 
describes it, is dense, coriaceous, and white as alabaster, though upon 
the eschar some vesicles appear, and by their presence suggest a false 
conclusion as to the vitality of the tissues upon which they rest. In 
from eight to ten days the slough is removed by suppurative processes, 
leaving a granulating surface, which bleeds readily when touched. It 
is frequently studded with pinhead-sized, white islands, which are 
points of regenerated epithelium budding from partly destroyed 
cutaneous glands. These islands of epithelium extend and coalesce, 
effecting the repair of extensive areas. In such cases the scar which 
results may consist of penny-sized, circular areas of normal integument, 
representing these islands, interspersed with scar-tissue. If the destruc- 
tion of tissue is deeper, granulation and the production of deforming, 
contracting scar-tissue results. The characteristics of the scar thus 
produced are: its great irregularity, its tendency to stellate radiation, 
and the production of ridges, folds, and pockets. 

Burns involving one-third of the body-surface are of grave portent, 
and those affecting one-half the body are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little com- 
plaint of pain. The causes of death in these fatal cases are generally 
obscure, as the postmortem results are usually negative. Gastric and 
duodenal ulceration, however, is often recognized. Overheating of 
the blood, heart-paralysis, oligocythemia, and actual destruction of 
leukocytes have all been supposed to be effective in bringing about 
dissolution. In cases in which life is prolonged to the third day, the 
complications of pyemia, erysipelas, and tetanus may arise. Lastly, 
exhaustion following fever, suppuration, hemorrhage, and visceral 
affections may lead to fatal results. 

Treatment. In the treatment of the simplest burns, rest, lotions of 
lead-water, and cool water, with the application of compresses, are 
usually sufficient to secure relief; occasionally, dusting-powders may 
advantageously be substituted. In the cases in which scrum is brought 
rapidly to the surface, with the production of vesicles and bullae, the 
latter should be punctured skilfully to give relief to tin 1 tension 1>\ the 
evacuation of their contents, but the roof-wall should be preserved, 
as it may subsequently form an attachment to the exposed derma 



266 HYPEREMIAS AXD INFLAMMATIONS 

beneath. For the relief of the severe pain experienced immediately 

after the burn, the use of carron oil and bandaging the part had best be 
employed. In localized eases pieces of linen spread with naftalan 
ointment and placed over the area give prompt relief, prevent 
infection, and promote more rapid healing. Where the burn is suffi- 
ciently extensive to confine the patient to bed, the open-air treatment 
may be employed to advantage. Continuous immersion in water 
having the temperature most agreeable to the patient, as practised by 
Ilebra in cases of severe and extensive burning, produces a speedy 
and certain amelioration of the pain and a favorable condition of the 
wounds, though it dot's not avert a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the sup- 
purative process in the skin is both active and extensive. In some 
cases disinfection with a 5 per cent, solution of phenol, or a 2 per 
cent, resorcin solution, should be followed by the application of pro- 
tective silk wet with a 5 per cent, solution of sodium biborateor bicar- 
bonate, and the whole enveloped either in borax-lint, antiseptic (mer- 
curic iodid) wool, carbolized gauze, or salicylated cotton. Over all, 
impermeable rubber tissue should be wrapped. Instead of the pro- 
tective silk, it is often better to use strips of sterile, moist, rubber tissue, 
] of an inch wide. These are laid smoothly and evenly over the sur- 
face with narrow spaces between them. The first layer then is crossed 
by a second at right angles to the first. The surface is thus practically 
covered with the rubber tissue, leaving, however, at each crossing 
of the strips small openings for the escape of secretion. Boric-acid 
water, or other feebl\ antiseptic solutions, may then be applied and 
changed as often as necessary without damage to the surface beneath. 

Skin-grafting may be required to cover the extensive ulcers left by 
the larger burns. 

Dermatitis Congelationis. — Exposure to extreme cold produces 
varying grades of inflammation of the parts (usually the ears, nose, 
cheeks, fingers, and toes), from a comparatively transitory erythema 
to deep, destructive processes, including gangrene. In the first degree, 
which usually follows short exposure to extreme cold, there occur 
erythema and swelling after the parts are warmed. During the freez- 
ing process there occurs slight pain, followed by loss of sensation, and 
the area presents a pale appearance, from contraction of the blood- 
vessels. As the circulation is restored, hyperemia and edema follow. 
Occasionally a more or less permanent redness supervenes. 

In the second degree the edema and erythema are increased, with 
the production of vesicles and bulla?. These undergo involution with- 
out the formation of scars. 

In the third grade gangrene may occur, with and without the for- 
mation of bulla?. The frozen part may become insensitive, white, and 
cold, without the circulation in it of blood- and lymph-currents. From 
this condition reaction occurs, with the formation of an eschar, differ- 
ing according to the severity of exposure to cold. If, however, beside 
the interference with the circulation, the tissue itself has been 



DERMATITIS 267 

destroyed, when reaction occurs the pari falls al once into gangrene; 
or there form bill he, larger than those described above, filled with an- 
guinolent serum; or the skin is smooth, marbled with bluish lines, 

whitish, cold, and insensitive. Gangrene ensues, followed by the well- 
known phenomena of the "line of demarcation/ 1 and, in favorable 
issues, suppurative separation of the dead part, granulation, repair, 

and cicatrization. As the injuries induced by congelation are more 
frequent upon the extremities, the bones, especially those of the dibits, 
largely participate in the losses of tissue. Septicemia and a fatal 
result may follow. 

Treatment. — The temperature should be gradually restored, as rapid 
warming results in painful and dangerous results from nutritional 
changes. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction performed in an apartment the air of which is cool, 
to prevent too energetic reaction. Friction with snow is employed with 
safety in America and on the steppes of Russia, where these accidents 
arc frequent and are grave in results. Perseverance for hours in this 
course is often rewarded with success in apparently desperate cases. 
Antiseptic dressings are usually demanded when sloughing and ulcera- 
tion ensue; and in severe cases resort to surgical procedures may be 
necessary. 

Dermatitis Medicamentosa. 1 — Synonyms: Drug Eruptions. Ger., 
Arzneiexantheme; Fr., Eruptions medicamenteuses. 

The importance of recognizing the fact that a given eruption is 
produced by an ingested drug can scarcely be overestimated from the 
point of view of the diagnostician. The errors committed in this 
connection are so frequent and so annoying to the patient that it is 
necessary for the physician to inquire very carefully, before treating 
any cutaneous disease, as to the medicaments previously swallowed 
by the patient, and also to be prompt to connect any aggravation of a 
cutaneous disease with remedies ordered by himself for internal use. 
Practically all of the lesions that occur in the various cutaneous dis- 
eases, from an evanescent urticarial wheal, or superficial, short-lived 
macule, to deep-seated ulcerative and gangrenous processes, may be 
induced by drugs ingested. Every primary and secondary lesion 
described as symptomatic of cutaneous disease may occur after the 
ingestion and absorption of different drugs. The difficulty encoun- 
tered in diagnosis lies in the fact that many different drugs produce 
identical symptoms; and, again, that a single drug may produce multi- 
form lesions. Arsenic alone may produce nearly all of the various lesions 
in susceptible subjects. It may be said, then, that with a few excep- 
tions a positive diagnosis as to the exact drug producing a given erup- 
tion cannot be made; but this is not of great importance, provided 
that one is sure that some one of the various drugs is responsible. 

1 For full details and bibliography «»f this subject, consull the treatise on Drug Erup- 
tions l>y Prince A. Morrow, New York, L887; and chapter by Ehrmann in MraeeL's 

Handbuch, vol. i, p. <;:<<). 



268 HYPEREMIAS AND INFLAMMATIONS 

Taken as a whole, drug eruptions have symptoms that are sufficiently 
characteristic for detection. In this work those eruptions produced 

by the action of drugs on the skin are described in the chapter devoted 
to Dermatitis Venenata. In this, particular chapter only those erup- 
tions produced by the ingestion of drills will he noted. Some drugs, 
however, such as belladonna, mercury, etc., produce similar symptoms 
whether they are applied locally or given internally. 

The major portion of drug eruptions are examples of angioneurotic 
phenomena, and these symptoms may be produced by many drugs, 
among which are quinin, antipyrin, belladonna, the antitoxins, etc. 
Only a few drugs, such as the compounds of iodin and hromin, pro- 
duce characteristic and diagnostic lesions referable without question 
t<» the particular drug. Some of the lesions produced by arsenic also 
are characteristic. While most drugs only exceptionally produce 
eruptions, others, such as iodin and bromin compounds, commonly 
do so; and it is only when the rashes occur to an unusual degree, or 
other manifestations become apparently grave, that special attention 
is directed to them. Souk- drugs produce cutaneous symptoms after a 
single dose, and that may be small; while others do so only after a long- 
continued demonstration or large dosage; and the most important 
factor in every case is idiosyncrasy. 

While some drugs may produce different cutaneous phenomena in 
different people, they usually produce a particular eruption in the same 
individual. 

The major portion of eruptions due to the ingestion of drugs are 
exhibited on the skin as angioneurotic or trophic disturbances, and 
resemble very much the dermatoses commonly described as due to 
toxemia-- inducing the simple and polymorphous erythemas, urticarias, 
and the more serious trophic disturbances exhibited on the skin as 
vesicles, bullae, ulceration, and gangrene. 

Symptoms.- As a rule, the eruptions from drugs appear suddenly 
and disappear soon after the withdrawal of the exciting cause; but 
the iodin and bromin group are exceptions to this rule. The latter 
usually appear only after long-continued use or large dosage, and may 
even appear after the discontinuance of the drug, and they are slow 
in undergoing involution. Commonly, a drug exanthem is brighter 
colored than the disease which it simulates, and is usually accompanied 
by sensations of itching or burning. The iodin and bromin group 
again are the exception. The eruptions as a class are usually more or 
less generally distributed and are symmetrical. Special areas, such 
as the face, neck, forearms (especially about the wrists), and lower 
limbs (particularly below the knee), are more commonly selected, 
though a more general distribution may occur. The exanthems of 
moderate degree are accompanied by mild, if any, constitutional symp- 
toms, but severe symptoms may accompany generalized and intense 
eruptions. These are especially likely to accompany the scarlatini- 
form and morbilliform varieties. 



DERMATITIS 

Etiology. Drug eruptions occur more commonly in women and 
children and in people of a neurotic temperament. Lack of proper 
elimination through disease of the kidneys is also an important factor; 
hut chief of all is idiosyncrasy. Large numbers of cases ar< 
in which extraordinary susceptibility is demonstrated. Stelwagon 1 
reports a case of unusual susceptibility to quinin. 

Pathology. A number of theories have been advanced concerning 
the pathogenesis of drug eruptions, to all of which legitimate objec- 
tions can he brought forward and sustained. The fact that idiosyn- 
crasy is the most important factor, and again that eruptions occur 
most commonly with the drugs that have a special effect upon the 
nerve-structures, both peripheral and central, makes the neurotic theory 
advanced by Morrow the most plausible in the majority of instances. 
It seems that in susceptible individuals the drug circulating in the 
blood produces irritation of the vasomotor centres of the peripheral 
nerves, thus inducing all the erythematous, morbilliform, and scarla- 
tiniform eruptions, which are those distinctly angioneurotic or toxic 
in nature. The more serious lesions which indicate interference with 
the local nutrition of the skin may be due, similarly, to the more marked 
effect on the trophic centres which regulate the nutritive processes. 
r l ne latter is the explanation brought forward in connection with the 
eruptions induced by the iodids and bromids. Engman and Mook 2 
have recently advanced what they term the rational theory to explain 
the pathogenesis of these eruptions. They believe that the lesions 
occur where there is a loss of tissue-equilibrium, due to local congestion 
already present from an old acne, seborrhea, or trauma, thus caus- 
ing a more severe local inflammation. But absence of implication of 
the sebaceous glands and hair-follicles in the process eliminates the 
theory that excretion of the drug by these avenues induces the eruption. 

Diagnosis. — The diagnosis of the various medicinal rashes does not, 
fortunately, demand a recognition of the essential peculiarities im- 
pressed upon each by the exciting cause, since in many eases such 
peculiarities do not exist. The same drug may, on the one hand, pro- 
duce a rash with symptoms widely differing in a group of patients; 
while, on the other hand, the urticarial resulting from the ingestion of 
"head-cheese," quinin, and chloral may be indistinguishable. But to 
establish the fact that a medicamentous eruption is present in any 
given case is a long step in the direction of reaching the precise cause 
that has been in that case effective. In general, the medicinal rashes 
arc remarkable for their sudden appearance, their symmetry, their 
diffusion over large areas of integument, the presence of itching, the ab- 
sence of fever (exceptions being noted in the eruption produced by such 
drugs as veronal), and their existence alike upon exposed and protected 
surfaces of the skin, thus hinting at the action of some cause not oper- 
ating externally. Excluding syphilis and the exanthematous fc\ ers, a 

' .lour. Cut. Dis., L902, \\, i'. 13. 
- Ibid., 1«H)(), xxiv, p. 502. 



270 HYPEREMIAS AND INFLAMMATIONS 

generalized rash of sudden occurrence should always raise the suspicion 
of a dermatitis medicamentosa. Similarly, in cases of preexisting 
disease — syphilis, eczema, or psoriasis — the sudden occurrence of 
lesions of a new type, widely diffused, or of rapid aggravation in situ, 
or of speedy extension in the area of those already in existence, should 
awaken the suspicion, if there he fever, of the exanthemata, and, with- 
out a febrile process, of the medicinal rashes. It is a matter of common 
experience, when examining patients on the eve of a macular syphilo- 
derm, or even long past the eruptive stage of the disease, to see their 
fact's, necks, and shoulders covered with an acneiform rash produced 
by potassium iodid. The practitioner cannot too strongly he urged 
to view with exceeding watchfulness the skin of a patient affected with 
any of the common disorders (eczema, acne, and psoriasis) when the 
eruption becomes anomalous as to type, distribution, or symptoms. 

Treatment. In the major portion of cases, it is only necessary to 
terminate the use of the drug, when recovery soon follows. In the 
more seriou> iodin and hroinin eruptions, elinhnative treatment is 
important, and a local dressing of salicylic acid or ammoniated mer- 
cury hastens recovery. Crocker recommends small doses of arsenic 
to hasten the slow involution of the large plaques occurring with these 
drugs. Arsenic i^ also of value in preventing the unsightly acneiform 
lesions occurring in patients to whom the iodids must he given in 
certain stages of syphilis. 

The following is hut an imperfect list of the drugs the internal admin- 
istration of which may be followed by an exanthem; imperfect, because 
without question many have yet to be recognized as possessing such an 
action. For convenience they are arranged in alphabetical order. 

Acids capable of producing macules, papules, erythema, and des- 
quamation, are nitric, tannic, benzoic (and sodium benzoate), and 
boric (and sodium borate). 

Aeon iff is said to be productive at certain times of marked diapho- 
resis, with the occurrence of vesiculation and considerable itching. 
The diaphoresis in an irritable skin may be responsible for the trouble. 

Antifebrin and Acetanilid occasionally produce an erythematous 
or maculo-papular exanthem, or, when long continued, may cause 
partial cyanosis. 

Antipyrin and Other Remedies of its Class (manufactured by the 
action of glacial acetic acid upon the petroleum products). — Ernst 1 
has been followed by many observers in recording rashes resulting 
from the administration of antipyrin. The symptoms are discrete 
and confluent patches of bright-red, scarlatiniform, erythematous, 
and pruritic macules or papules. Veiel 2 reports edema with bullae 
upon the lips and toes and over the palate, wdth urticarial lesions of 
the palms and soles, after ingestion of antipyrin. Brocq, Darier, and 
others have reported cases in which antipyrin has produced a more 
or less persistent erythema in the form of isolated, scattered, sharply 

1 Centrabl. f. klin. Med., 1885. 2 Archiv, 1891, xxiii, p. 33. 



DERMATITIS 



271 



defined plaques. These plaques are usually Pew in number, and they 
tend to return in the same sites whenever the susceptible individual 
ingests the drug. The redness and pigmentation may persisl for 
several weeks. Wickham 1 reports an antipyrin rash which simulated 
perfectly a macular syphiloderm. 
Antitoxin. (See Serum Eruptions.) 

Fig. 57 




( reneralized pigmentation and keratosis following long-continued use of arsenic. 

Arsenic. 2 —Erythematous, vesicular, papular, and, much more rarely 
pustular, bullous, and ulcerative lesions occur upon the face, the hack, 
and the hands after the ingestion of arsenic. The well-known effects 
of the administration of the drug in toxic doses upon t he mucous mem- 
branes of the eyes, nose, and mouth need not be described in this con- 



1 Berliner Monatshefte, 1002, xxxv, p. 137 (with review of literature). 
'Brooke-Roberts: The Action of Arsenic on the Skin, as Observed in tli 
Epidemic of Arsenical Beer-poisoning, Brit. Jour. Derm., L901, xiii. p. L21. 



Recenl 



272 HYPEREMIAS AND INFLAMMATIONS 

aection, nor yet the grave gangrenous symptoms, with osseous necrosis, 
that have been observed in workers in the metal. 

"A bright-red, searlatiniform blush, with a few isolated vesicles, has 
covered both shoulders of a young woman with a delicate skin after 
taking three medicinal doses of Fowler's solution, the eruption being 
present, but less distinct, upon her face and hands. In two cases the 
rash in polymorphic type was limited to the hands alone" (Hyde). 

Young patients who have taken arsenic in the largest medicinal 
doses for relief of chorea often present as a result a dark discoloration 
chiefly of the skin of the chest and the neck, but also of other parts of 
the body. This discoloration is suggestive of the bronzing seen in 
Addison's disease. In some instances there are no other cutaneous 
symptoms. Guaita and Liege 1 noted these phenomena usually in the 
fifth month after ingestion of the drug. 

Long-continued use of arsenic may produce keratosis of the palms 
and soles of severe grade, obstinate character, and occasionally grave 
results. Administered tor relief of psoriasis, the resulting keratoses 
have later developed into epitheliomata of malignant type. 2 

By far the larger number of rashes are, however, produced in per- 
sons previously suffering from the cutaneous disease for the relief of 
which the drug i> administered. Here the t<>\ir effect i^ declared by: 
first, increased hyperemia of the skin, visible in an erythematous 
patch, or beneath the scales of a squamous patch, or as an areola 
of bright-red line about any aggregation of lesions; second, by simple 
aggravation of the type of a disease already in existence (recur- 
rence of acuity in a subacute eczema ) ; third, by rapid peripheral exten- 
sion of a disease which had previously been well limited in contour; 
or, fourth, by converting a disease exhibiting uniformity of lesions into 
one characterized by multiformity. Each of these results might be 
illustrated by cases. 

In a >erie> of eight cases of poisonous effects produced by arsenical 
paper-hangings, and reported by Brown, 3 there were, curiously, no 
cutaneous symptoms. 

Aspirin induced an angioneurotic eruption in two cases recorded 
by Anderson. 4 

Belladonna. — The well-known erythematous, searlatiniform or red- 
dish efflorescence produced by belladonna and its alkaloids is usually 
limited to the upper segment of the body, but it may become general- 
ized. It is said to occur more frequently in children, probably because 
belladonna has been administered largely to individuals of that age 
under the delusion that it is useful as a prophylactic in scarlatina. 
Very disagreeable and even dangerous results have followed the instil- 

1 Hamburger: Arsenical Pigmentation and Keratosis, Johns Hopkins Hosp. Bull., 
1900, xi, p. 87. 

2 Hartzell, Amer. Jour. Med. Sci.. 1899, cxviii, p. 265; and Darier, Annales, 1902, iii, 
p. 1126. 

3 Paper read before the Boston Society for Medical Observation, March 6, 1876. 

4 Canadian Practitioner and Review, September, 1912, xxxvii, No. 9; abstr. Jour. 
Cut, Dis., 1912, xxx, p. 754. 



DERMATITIS 273 

lation into the eye of atropin as a mydriatic, the rash being accom- 
panied by constitutional symptoms. 

Boric Add. 1 Erythema, papules, vesicles, bullae, and lesions resem- 
bling those of erythema multiforme (Fordyce) are reported as follow- 
ing the ingestion, or absorption, of boric acid. A mild form of acute 
exfoliative dermatitis, with temporary loss of hair, is recorded as 
occurring after prolonged use of the remedy. 

Modadewkow reports a case in which the pleura was washed out 
with a 5 per cent, solution of boric acid, a part of which was not re- 
moved. There occurred as a result an erythematous rash over the 
face, the trunk, and the extremities. 



Fig. 58 




Dermatitis medicamentosa. (Howard Fox.) 

Bromin and its Compounds. — A full account of the cutaneous 
effects of bromin and its compounds, when administered internally, is 
contained in a paper on medicinal eruptions, read in 1880, by Van Ilar- 
lingen,of Philadelphia, before the American Dermatological Association, 
Acneiform lesions, pustules, macules, maculo-papules, papules, eczem- 
aform moist patches, furuncles, urticarial wheals, scales, and ulcers 
have been induced by swallowing the bromids of potassium, sodium, 



Wild, Lancet, L899, i, p. 23 (with bibliography). 



is 



274 HYPEREMIAS AND INFLAMMATIONS 

ammonium, and lithium. By far the commonest, are the acneiform 
and pustular lesions, occasionally accompanied by itching, which 
appear upon the face and the upper portion of the trunk, though the 
rash may he very distinct upon the genital region. Duhring reports 
an interesting observation of a patient in whom the eruption simu- 
lated closely the maeulo-papular syphiloderm, the patient having 
taken a bromin salt for three years. The eruption first appeared 
within five or six days after decreasing the dose. Kaposi observed a 
case of bromid-rash in a nine-months-old suckling, the mother 
having taken 120 grammes of potassium bromid in two months, 
without exhibiting traces of eruption. 

A remarkably characteristic exanthem is produced by the adminis- 
tration of potassium bromid, especially to infants and young children. 

Fig. 59 




Dermatitis medicamentosa due to bromids. 

The lesions are condylomaform, quite numerous, and conspicuous 
about the face and neck, where they are packed closely together, but 
they are also seen on other parts of the body. The small-coin- to nut- 
sized elevated nodules are usually flattened; and they often resemble 
carbuncles, as they have a cribriform summit, on which multiple 
points of imprisoned pus are visible. This rash, though rare, has 
been carefully studied and well illustrated by chromo-lithographic 
reproductions. 

Recent literature is replete with reports of examples of vegetating, 
tuberous, papilliform, and fungoid lesions produced by the ingestion 
of the bromids. Kudisch, 1 Versilovoi, 2 Pospielov, 3 Whitehouse, 4 

1 Zeitschrift, 1912, xix, p. 713; abstr. Jour. Cut. Dis., 1913, xxxi, p. 281. 

2 Russki Joornal Kojnikh E Venericheskikh Boleznei, April, 1913, No. 4, p. 311; 
abstr. Jour. Cut. Dis., 1913, xxxi, p. 1061. 

3 Ibid., March, 1913, No: 3, p. 200; abstr. ibid., p. 1060. 

4 Jour. Cut. Dis., 1913, xxxi, p. 497. 



DERMATITIS 275 

Oulmann, 1 Burns, 3 and many others have described cases representing 
these varieties. One of the authors 8 reported a group of this type 
resembling blastomycosis. Stelwagon and Gaskill 4 reported a similar 
ease. A further report of the same ease is made by Gaskill. 5 

T. C. Fox and Gibbes report these eondylomai'orm nodules in the 
ease of an infant, in which the histology of the lesions was carefully 
studied; and Fay, in a child eleven months old, also recognized an 
exanthem which had been mistaken for molluscum epitheliale. These 
lesions are somewhat similar to the eondylomaform rash seen in chil- 
dren after the administration of potassium iodid. The lesions may 
appear for some weeks after the drug has been discontinued. 

Browse, of Cambridge, England, recommends for relief of these 
symptoms the application of a solution of salicylic acid, 1 grain to the 
ounce (0.066-30.) of water, frequently applied on lint, he having suc- 
cessfully treated in this way sores as large as the palm of the hand. 

Cannabis Indica. — An eruption produced by the ingestion of this 
drug was observed by Dr. Hyde 6 in the case of an adult male, who 
was covered extensively with papulo-vesicular lesions after swallowing 
1 grain (0.066) of the extract. 

Cant liar id <us\ — Erythematous and papular eruptions are reported 
in a few instances. 

Capsicum. — Erythema results occasionally. Allen reports a papulo- 
vesicular eruption following the internal use of the drug. 

Chloral. — An erythematous rash is the commonest of the eruptions 
produced by chloral, though wheals, red and yellowish papules, vesicles, 
pustules, and petechial blotches have been observed. The rash occurs 
upon the face, the neck, the trunk, and the limbs, of the latter espe- 
cial ly on the extensor surfaces. In a man of advanced years and 
totally deaf, who had slept only under the influence of chloral for four 
years, discrete scaly patches as large as saucers covered the hands and 
the lower extremities. 

Martinet 7 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face and neck, the front of the chest, the extensor surfaces of 
the larger joints, and the dorsum of the hands and feet. There was no 
pyrexia or indisposition, but in some eases there were dyspnea and 
cardiac palpitation. 

Chhralamid. — Pye-Smith reports a ease in which this drug pro- 
duced a scarlatiniform eruption, involving the mucous membranes, 
accompanied by fever, and terminating in free desquamation. 

Chloroform- During inhalation an erythema of short duration, and, 
rarely, purpuric spots are noted. 

Cod-liver Oil. — According to Farquharson, cod-liver oil after being 
swallowed is capable of producing an acne. This result is traceable 
to inferior qualities of the oil. 

1 .lour. Cut. Dis., L911, xxix, p. S.V.). 2 Ibid., p 

"Ibid., L909, xxvii, p. 445. * Ibid., :xi, p. 129 

Jour. Aiiicr. Med. Assoc, 1914, lxii. p. 912. 

" New York Med. Record, May 11, 1878. 7 Thesr de Paris. 1879. 



270 HYPEREMIAS AND INFLAMMATIONS 

Condurango. — Guntz 1 reports the occurrence of f uruncular and acnei- 
form lesions in twenty patients out of one thousand who were taking 
condurango for the relief of syphilis. 

Copaiba and Cubebs, — Occasionally, the ingestion of copaiba is fol- 
lowed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the abdomen, but often completely covering 
the body-surface. The rash may occur in dark, mulberry-red petechia 4 , 
and always is accompanied by itching. Inasmuch as the drug often 
is administered for the relief of a venereal disorder not syphilitic, care 
should be taken not to confound the eruption it may excite with the 
early macular syphiloderm. Cubebs is followed much more rarely 
by a similar result. 

Digitalis— In Behrend's treatise on Diseases <>f flic Shin- reference 
is made to cases in which macular and maculo-papular rashes succeeded 
the ingestion of digitalis. 

Ergot rarely gives ri>c to vesicles, pustules, small furuncles, or pete- 
chias. Circumscribed areas of gangrene on the extremities are more 
common. 

Eucalyptus produced an eruption of bright-red, cherry-red, and 
brownish-red papules and nodules, mostly circumscribed, but confluent 
on toes and fingers, in a case reported by ()ppenheim. ;i The lesions 
were situated on the hands and feet chiefly, and were accompanied by 
slight itching and preceded by mild general symptoms. 

Fibrolysin injections producing a general erythema are recorded by 
Tausardand Uaillet. 1 

Guiacum produced a general eruption of large, elevated, erythema- 
tous plaques in a case recorded by Kingsbury. 5 

lodin and its Compounds.*— Potassium iodid is responsible for the 
larger number of all eruptions among medicinal rashes. The frequent 
employment of this drug and the very marked influence it possesses 
over the skin render the study of these morbid results important. Un- 
like many of the other substances in the list of drugs, the iodin com- 
pounds are followed by some species of rash in probably the larger 
number of all persons who swallow them. As is true also with the 
bromin compounds, the eruption may persist, or even first appear, 
after the drug has been discontinued. 

The resulting lesions may be macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or may be circumscribed subcutaneous 
abscesses. In appearance the rashes produced by iodin and its com- 
pounds may simulate those of every other dermatitis. 

1 Vierteljahr, 1882, ix. 2 Braunschweig, 1879. 

3 Derm. Wochenschrift, 1912, liv, p. 224; abstr. Jour. Cut. Dis., 1912, xxx. p. 304. 

4 Bull. Soe. Fr. de Derm et de Syph., 1908, p. 83; abstr. Jour. Cut. Dis., 1909, xxvii, 
p. 44. 

5 Jour. Cut, Dis., 1912, xxx, p. 214. 

6 D. W. Montgomery, Trans. Med. Soc. of State of Cal., 1900 (review of subject with 
bibliography); and Rosenthal, Archiv, 1901, lvii, p. 3 (review of subject, with account 
of histological changes in one case). 



DERMATITIS 

The macular rash is seen best fully developed over the upper extremi- 
ties in discrete erythematous patches or as ;i diffuse blush. Generally 
the rash is displayed symmetrically. The hands arc often affected, and 
suggest in appearance the hands of the anilin-worker. The rash 

assumes at times the papular type, with special production of papules 

lipOE the face. 
Berenguier describes a scarlatiniform rash of sudden occurrence, 

with numerous minute, discrete vesicles upon the surface of the skin. 
Eczemaform eruptions with abundant serous exudation are also re- 
ported. 

A number of cases are on record in which the administration of the 
drug was followed by the production of bullae. Bumstead, Taylor, 
Duhring, Tilbury Fox, Finny, and one of the authors have described 
such bullae in adults as well as in children. 1 Hallopeau 2 also reports a 
fatal case in which a bullous eruption followed the ingestion of potas- 
sium iodid. The eruption occurred chiefly about the head and neck 
and the upper extremities. The significant rarity of vesicular and 
bullous lesions in acquired syphilis suggests that at least some of the 
cases of this condition on record were those of rashes induced by the 
remedy given for the relief of the disease. 

A careful analysis of these bullous rashes leads to their division into 
three categories: first, those occurring, often with fatal results, in 
cachectic adult patients; second, those occurring as part of the erup- 
tive lesions in a polymorphic group; third, those occurring in well- 
nourished children, and taking on the appearance of molluscum epi- 
theliale and condyloma-lesions, usually compounded of papulo-vesicles 
and pustules. Frythemata of a similar type have also been recognized 
after the ingestion of potassium bromid by infants. 

The pustules induced by the administration of iodin compounds 
are seen chiefly upon the face, the neck, the trunk, and the arms. They 
are usually seated upon a firm base, and may be followed by cicatrices. 
Duhring has seen an annular patch upon the forehead, made up of 
minute vesico-pustules, which eventually developed into a globular, 
violaceous mass nearly two inches in diameter. Large, cherry-sized, 
tubercular or papillomatous elevations, abruptly rising from the 
>nrface of the integument, may present a cribriform structure, which 
shows the open ducts of several suppurating follicles (chin, cheek, 
nose). A few cases are reported in which fungating tumors were 
found, producing an appearance almost identical with that of mycosis 
fungoides. Neumann 3 calls attention to the fact that these severe 
forms of iodid-eruption occur in patients suffering from albuminuria. 

The purpuric rash occurs in petechial macules, discrete and miliary. 
situated chiefly on the lower extremities. In a case reported by Mac- 
kenzie (quoted by Van Harlingen) a dose of 2] grains (0.166) taken 
by an infant was followed by a fatal result after petechia 1 appeared. 

1 Jour. Cut. Dis., L886, iv, p. 383. - Union im'<l., iss2. xxx, p. 481. 

\i.l.i\. 1899, xlviii, p. 323. 



27S HYPEREMIAS AND INFLAMMATIONS 

Iodoform. — The internal administration, or the absorption through 
wounds, of this drug has been followed by macular, papular, vesicular, 
bullous, petechial, and mixed eruptions. Grave, and even fatal, sys- 
temic results are noted, including fever, delirium, emaciation, and 
nephritis. (For the local effects of the drug, see Dermatitis Venenata). 

Jaborandi and PUocarpin are capable, when ingested, of inducing 
free diaphoresis; erythematous macules, wheals, and pinhead-sized 
papules have been seen upon the surface as a result. 

Mercury. — Mercury, when ingested, is reported to have produced 
an erythematous rash upon the surface of the skin. In view of the fact 
that the metal has been, in its various compounds, administered for so 
long a period of time and for so many various diseases without the 
production of cutaneous symptoms, it is a fair hypothesis that in the 
few reported cases there was coincidence rather than causation. Mer- 
curials, when applied to the external surface of the body, are, as is 
well known, capable of exciting in various degrees cutaneous irri- 
tation and inflammation. 

Midal, a substance containing pyramidon, produced erythema, 
wheals, and purpuric lesions on the legs, accompanied by itching, in 
a case recorded by Bcchct. 1 

Opium and its Alkaloids. Erythema, wheals, and occasionally 
intense itching, with edema and subsequent desquamation, have 
followed the ingestion of opium and several of its alkaloids, notably 
morphin. In its mildest expression, this cutaneous effect is limited 
to a characteristic itching about the nostrils, that can be perceived in a 
large proportion of all patients as soon as the general effect of the opiate 
becomes apparent. In some patients there may follow- an intense and 
distressing general pruritus without efflorescence, and it is certain that 
the subsequent urticarial efflorescence is caused by the free diaphoresis 
which the medicament induces. The fact is a matter of practical 
moment, as the use of an anodyne for the purpose of procuring sleep 
for a patient tormented with a nocturnal pruritus would seem to be 
occasionally indicated. Inasmuch as chloral, potassium bromid, and 
the opiates are all capable of aggravating such distress, great caution 
is needful in such emergencies. In general, it may be said that the 
employment of these and similar remedies for the relief of pruritus 
should be interpreted as a confession of weakness on the part of the 
physician, who ought to be able to alleviate the distress of his patient 
by a judicious employment of topical remedies. 

Petroleum and its products are responsible for a large list of medica- 
mentous rashes (see Antipyrin). 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of a 
young girl who exhibited a pemphigoid rash after the ingestion of phos- 
phoric acid. According to Farquharson, phosphorus itself is occasion- 
ally responsible for purpura, with gastro-intestinal derangement and 
jaundice preceding a fatal issue. 

1 Jour. Amer. Med. Assoc, 1912, lix, p. 1289. 



DERMATITIS 279 

Podophyllin. Winterburn 3 reports that those who work in resinoid 
podophyllin arc liable to suffer, as a consequence of this exposure, 
from a cutaneous disease of the scrotum. 

Potassium Chlorate. Stelwagon and others report that papule- and 
macules have followed the use of this remedy, administered in the 
form of tablets. 

Quinin, Cinchona, and Cinchona Alkaloids— Morrow- collected the 
records of over sixty cases of quinin-exanthem, and showed that its 
prevailing type is exanthematous, the rash being of a vivid hue, dis- 
appearing on pressure, and resembling scarlatina. Other lesions pro- 
duced are wheals, papules, vesicles, petechia^, hemorrhagic purpura, 
bullae, and in one instance an intense localized dermatitis, with begin- 
ning gangrene, of the scrotum. Bullous formation is rare following 
ingestion of quinin. Trimble 3 reports an example of this form. In 
some of the cases the rash appears on repetition of the dose, and even 
after recourse to other alkaloids. The subjects are mostly women. 
As with most of the other exanthem-producing drugs, small doses 
suffice for the effect where the idioseyncrasy exists. The rash has 
been studied in an adult male, who, after taking 2 grains (0.133) of 
quinin sulphate for the first time in six years, exhibited an efflores- 
cence (over the entire surface of the body) of discrete, finger-nail-sized, 
salmon- and pinkish-tinted, scarcely elevated patches, accompanied 
by moderate itching. A repetition of the dose was followed by a 
recurrence of the exanthem. 

In several cases desquamation is reported as resulting from the rash. 
As to the occurrence of the general symptoms recognized under the 
title "cinchonism" (tinnitus aurium, etc.), these may and may not 
accompany the lesions. Morrow makes the pertinent suggestion, in 
view of the frequent similarity of the rash to that exhibited in scar- 
latina, that many cases hitherto recorded as recurrent attacks of that 
disease and measles, with other anomalous cutaneous eruptions, may 
have been instances of quinin-exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases in which these 
substances after ingestion produced cutaneous symptoms have been 
made by Ileinlein, Wheeler, and Freudenberg, all cited by Van 
Ilarlingen. The symptoms were diffused redness, urticarial lesions, 
vesicles, pustules, petechia?, and vibices, accompanied by intense itch- 
ing and followed by desquamation. Engman 4 reports an interesting 
case, including the histology of the lesions. 

Salipyrin. — Edema of the skin and actual loss of tissue have resulted 
from the administration of gramme doses of salipyrin to a man aged 
fifty-four years (Schmey). 

Salvarsan. Salvarsan and neosalvarsan may produce a variety of 
eruptions, the most common forms being an urticarial erythema and 
urticaria. Occasionally, a scarlatiniform or morbilliform erythema, 

1 Louisville Med. News, L882, xiii, i). 187. 

2 New York Med. .lour., 1880, xxxi, p. 244. 

Mour. Cut. Dis., 1«.)10, xxviii. p. 194. ' [bid,, L899, xvii, |». 555. 



280 HYPEREMIAS AND INFLAMMATIONS 

bullous and vesicular lesions, and, rarely, gangrene, may follow their 
use. 

Santonin.- A generalized eruption of urticarial lesions seated upon a 
reddened surface and accompanied by edema is reported by Sieveking 
as occurring in a child to whom santonin has been administered as a 
vermifuge. 1 

Serum Eruptions.* — Tuberculin, diphtheria-antitoxin, and the vari- 
ous vaccines used as therapeutic measures frequently produce in sus- 
ceptible individuals cutaneous exanthems. As the antitoxin of diph- 
theria is used so commonly today, the exanthems produced by its 
employment should be recognized. 

Frequency. Owing to the fad thai different serums produce erup- 
tions in varying proportions, and also to the fact that accurate records 
are kept chiefly in hospitals, where the injections are used as a routine 
measure, and also by a few men specially interested in the matter, the 
exact proportion of persons displaying eruptions in relation to the 
whole number treated is difficult to determine. Ilartnng collected 
data from the literature on the subject, and from the reports of twelve 
observers found 294 eruptions resulting from 2()(>1 injections, an 
average of 11.1 per cent. 

Date- The appearance of these eruptions may occur from one to 
thirty days after the injection. The majority appear from the sixth 
to the tenth day. 

Character. The important exanthems in the order of frequency of 
occurrence are the following: urticarial, polymorphous, erythematous, 
scarlatiniform, morbilliform, vesicular and bullous, and purpuric. 
The last three are rare. The majority are urticarial, and may be 
ordinary urticarial wheals or urticarial erythema. The scarlatiniform 
and morbilliform varieties closely resemble the disease after which they 
are named. Mixed types are common and aid in diagnosis. Edema, 
especially of the face, about the eyelids, also of the penis, scrotum, 
and feet, is not infrequently noted in association with these eruptions. 
The distribution of the lesions is irregular. While they may occur on 
any part of the cutaneous surface, the sites of predilection are about 
the arms, legs, buttocks, and trunk. The face occasionally may be 
attacked. The first appearance of the eruption is commonly about the 
site of injection. It is frequently noted that the eruption appears 
within twenty-four hours at the site of the injection and soon clears 
but reappears later generalized. The extent of the eruption varies 
from a few isolated, scattered patches to a profuse exanthem, involving 
almost the entire cutaneous surface. Its duration is commonly about 
two days, but it may persist for three, four or five. Purpuric lesions 
naturally persist for a longer period. The eruption may recur within 
a few days after disappearance, or after some weeks. The dates of 
recurrence vary from three to seventeen days. More than one recur- 
rence may happen. 

1 Brit. Med. Jour., February 18, 1871. 

2 Welch and Schamberg, Treatise: Acute Contagious Diseases, pp. 754-760. 



DERMATITIS 281 

These rashes are eommonly accompanied by constitutional disturb- 
ance of varying degree. There is usually a rise in temperature, with 
its accompanying symptoms. While this rise usually does not exceed 
101° to 102°, it may be as high as 10.")°. The fever lasts from one to 
three days, subsiding with the disappearance of the eruption. Head- 
ache, a certain amount of prostration, and arthralgia are common 
accompaniments. The joint-pains are valuable aids in diagnosis. 

It is believed that these cutaneous manifestations are induced by the 
serum per se, and that the antitoxic material has little to do with their 
production. Similar eruptions have been produced repeatedly by 
non-immunized serum. 

Sodium Benzoate. — Rohe 1 reports two cases in which an erythem- 
atous rash, with well-defined border, accompanied by itching; and 
slight desquamation, occurred during the use of sodium benzoate. 
The patients were a woman, aged thirty-five years, and a boy suffer- 
ing from diphtheria. The eruption disappeared on discontinuance of 
the remedy, and was made successively to appear and disappear by its 
alternate use and disuse. 

Sodium Biborate. — Gowers 2 reports the occurrence, especially on 
the arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of sodium biborate. Some of the resulting 
patches were one and a half inches in diameter. Three cases in all are 
collated. In two the eruption faded when a solution of arsenic was 
added to the sodium salt. 

Stramonium. — Deschamps 3 reports an erythematous rash after the 
administration of the thorn-apple. 

Strychnin. — Skinner (cited by Van Harlingen) reports a case in 
which an eruption of six weeks' duration ensued upon the administra- 
tion of quinin and strychnin together; the former in the dose of 1J 
grain (0.1), the latter in the dose of ^t grain (0.0025). 

S ul phonal. — Diffuse macular and scarlatiniform eruptions are seen 
occasionally. Vesicular and purpuric lesions have also been reported. 

Tanacetum. — A case of varioliform eruption produced by the inges- 
tion of 1J drachms (6.) of the oil of tansy, administered for aborti- 
facient purposes, is reported by Potter. 4 There were antecedent clonic 
convulsions. The result was not fatal. 

Tar and Turpentine. — Erythematous, vesicular, and papular rashes 
are reported as resulting from the ingestion of these substances. 

Veronal. — Wills, 5 House, 6 Bulkley, 7 Wooley, 8 and others have re- 
ported instances of eruptions produced by this drug. Their occur- 
rence is due to idiosyncrasy, and the lesions belong to the group of the 
angioneurotic dermatoses. They may be exhibited as local or general 

1 Maryland Med. Jour., 1881, viii, p. 91. * Lancet, 1881, ii, p. 546, 

:i I Sited by I luhring. 

1 New England Med. Jour., October 15, 1881. 

i Brit. Med. Jour., March 3, 1000. 

•Jour. Ani.r Med. Assoc, 1007, xlviii, p. 1349. 

• [bid., 1007, xlviii, p. L865. s Ibid., 1007. xlix, p. 2153. 



282 HYPEREMIAS AND INFLAMMATIONS 

exanthems. Erythema, large maculo-papules, vesicles, oval and cir- 
cinate patches with dark centres resembling insect-bites, scarlatiniform 
erythema, and edema, especially of the face, have been described. On 
clearing, brownish stains and petechial spots remained for a time. 
Constitutional symptoms of moderate grade accompanied the general 
eruption. Pollitzer 1 recorded a case with erosive lesions in the mouth 
and about the anal region, accompanied by systemic symptoms, 
including urinary changes. The author has recently seen a similar 
example. The patient had been in the hospital for some weeks suffer- 
ing with psychosis and had been given ") grains of veronal each evening. 
The eruption had a generalized distribution and appeared first on the 
extremities. The face was red, swollen, and edematous. The erup- 
tion on the arms and trunk was morbilliform in character, in certain 
areas large plaques being present in addition. Intense itching accom- 
panied the eruption. The temperature ranged from 100° to 103° for 
several days. The process subsided in about eight days. 

The following medicaments may be added to the list of drugs capa- 
ble of producing rashes when administered by the mouth : 

Anacardium, alcohol, bitter almonds, antimony, argenti ultras, benzol, 
chinolin, bittersweet, capsicum, duboisin, ferrous iodid, guarana, kava- 
Jcava, creosote, resin, castor-oil, ipecacuanha, hyoscya m us, luctophenin, 
matico, lead and Its com pounds, mesotan, sulphur and calcium sulphide, 
rerutrum riride, cocaiu, conium, pimpinella, rhubarb, and ralerian. 

Many of these drugs have been effective in but few instances. There 
is no reason why the list should not in the future be greatly enlarged, 
as it is probable that every medicament is capable of producing a tem- 
porary efflorescence when the system exhibits a special sensitiveness 
to its action, the character of the eruption depending largely on 
individual idiosyncrasies, and on the circumstances (including the 
condition of the tissues) attending the administration of the drug. 

Feigned Eruptions.— Synonyms: Dermatitis Factitia, Hysterical Der- 
mato-neuroses, Hysterical Gangrene, Neurotic Gangrene, Spontaneous 
Gangrene, Erythema Gangrenosum. 

Definition. — Feigned eruptions occur in all degrees of dermatitis, 
from a simple erythema of a few days' duration to the various vesicular, 
bullous, gangrenous, and ulcerating lesions. The mild and super- 
ficial forms are the more common, but superficial gangrene and ulcers 
are not infrequently seen. The degree and severity of the process 
depend not only upon the agent employed, but also upon the strength 
of the solution, the duration of the application, and the susceptibility 
of the tissues to which the agent is applied. Thus, a moderately weak 
solution of phenol, if applied for a few minutes only, will produce in 
most individuals an erythema or superficial dermatitis of a few days' 
duration. -If the solution be stronger, or if a weaker solution be 
allowed to remain in contact with the skin longer, severer forms of 
inflammation and even gangrene may result. 

1 Jour. Cut. Dis., 1912, xxx, p. 185 (with additional literature). 



PLATE IV 





• 



Dermatitis Faetitia. 



DERMATITIS 283 

The methods employed in the production of these lesions are varied 

and often difficult to detect. Many different animal, vegetable, and 
mineral substances have been used for the purpose. Among those 
most commonly employed may he mentioned carbolic acid, croton-oil, 

Spanish fly, mustard, various acids and caustics, lye, and cresoline. 
Other methods include burning with hot-water bottles, matches, hot 
metal; and friction with the finger, pieces of wood, or other rough 
material. 

Occasionally, a skilled malingerer succeeds in imitating more or less 
closely certain definite cutaneous disorders. Among those so imitated 
may be named sycosis, favus, alopecia, ringworm, scabies, bromidrosis, 
hemidrosis, chromidrosis, erysipelas, abscesses, and syphilis. Patients 
with an eczema or other cutaneous disorder may aggravate or pro- 
long the same and make the interference very difficult of detection, 
even while under treatment. 

Diagnosis. — The diagnosis of feigned eruptions is usually not diffi- 
cult for one familiar with cutaneous diseases, as the lesions do not 
correspond with those of any recognized disorder. As a rule, the lesions 
all occur within easy reach of the patient's hands, and are most numer- 
ous on the anterior surfaces of the body; on the left arm, forearm, 
and hand; the lower extremities; and right side of the face and neck; 
that is, all regions easily reached by the right hand. In case of a left- 
handed individual, the regions most accessible to that hand would, of 
course, show the largest number of lesions. The palms, soles, eyelids, 
mouth, nose, ears, scalp, and genitals are usually spared. 

The lesions are always sharply outlined and of unusual, often fan- 
tastic, shapes. They appear suddenly, at irregular intervals, usually 
one or two at a time, and run a fairly rapid course. When fluid caustic 
is used, it frequently happens that one or more drops run dowm the skin 
from the point of application, leaving a characteristic streak, which is 
usually lighter in color and shows a less degree of inflammation than the 
patch from which it depends. When the caustic is applied with a needle 
or pin, as is frequently the case in gangrenous areas, the border shows 
an irregular, finely jagged or serrated (saw-tooth) edge, made by the 
numerous punctures in the advancing border. When gangrene is 
present, it is usually very superficial, and separated from the normal 
skin by a narrow, vivid-red line. The fingers, nails, or some article of 
the clothing are often stained by the agent employed. 

Subjective sensations, usually pain and burning, may be greatly 
exaggerated by the patient, who will then cringe or jump at the slight- 
est touch during the examination and will complain bitterly of the dis- 
tress caused by the simplest and lightest of dressings. On the other 
hand, the areas may be largely anesthetic, and some of these individuals 
like to exhibit their ability to endure pain. Many of the patients 
enjoy mystifying their medical attendant by predicting from twelve 
to twenty-four hours in advance the exact areas upon which new 
lesions will occur, claiming that during this period they experience in 
these areas a sense of heat and burning and other queer sensations. 



284 



HYPEREMIAS AND INFLAMMATIONS 



Further aids to diagnosis may be found in the general characteristics 
of the patients; the unusual history of the disorder; the discovery of 
anesthetic areas, especially of the fauces and conjunctiva; and other 
evidences of hysteria. Finally, if necessary, a fixed dressing that can- 
not he removed without detection may he used to clear the diagnosis. 

The patients presenting feigned eruptions may he roughly divided 
into two classes: First, deliberate malingerers, such as criminals, 
soldiers, sailors, and others desiring to escape punishment or service; 
servants, nurses, and those desirous of avoiding disagreeable duties 
or surroundings; and paupers or mendicants seeking charity, hospital 
accommodations, or other assistance. Second, hysterical and neu- 
rotic individuals, chiefly women and girls, who inflict these injuries 
upon themselves tor reasons not always definitely recognized. With 
this cla^s of patients, there is frequently a desire, more or less defi- 



I i... 60 




Dermatitis factitia, produced by potassium hydrate. (Foerster.) 



nitely recognized by the patient, to escape from disagreeable duties or 
surroundings, to gain attention, sympathy, interest or pity, or to 
achieve notoriety. The sexual element is not infrequently present. 
Awakening sexual desire, possibly not definitely recognized, in the 
developing girl; excessive or abnormal sexual activity; orgasm in- 
duced by torturing the skin; and a certain satisfaction experienced 
through exposing the body for examination, are features recognized 
in some of these cases. In some instances, the patient, while not recog- 
nizing any motive, states that she is subject at times to sudden irre- 
sistible impulses to produce these lesions. Such impulses may be the 
result of "suggestion" or of the "fixed idea." In a large proportion of 
cases the factitious eruption is preceded by some light wound or abra- 
sion of the skin to which an antiseptic dressing has been applied. The 
patient is thus provided not only with a source for the suggestion but 



DERMATITIS 



285 



also with the means for carrying if out. The extent to which hys- 
terical young women will injure themselves is Illustrated in two of the 
author's patients, both of whom submitted to amputation of the fingers, 
jiiid one demanded amputation of the entire hand, for gangrene pro- 
duced by themselves with carbolic acid. 

Treatment. The chief object to be attained for relief of these patients 
is to induce them to acknowledge the facts. New lesions then cease 
to appear and the management of existing lesions should be in accord- 
ance with the rules laid down in the chapter on Dermatitis. 

X-ray Dermatitis. — The symptomatology, etiology, and pathology of 
.r-ray dermatitis are considered under Radiotherapy. 

Treatment. — A better understanding of the possibilities of the .r-rays 
has developed a technique the careful following of which should pre- 
vent severe .r-ray burns, except in rare instances where it is thought 



Fig. 61 




Radio-dermatitis, third degree, upon keratodermia. 



advisable to risk the danger of such a burn for the sake of quickly de- 
stroying a rapidly progressing malignant growth. Even the mild forms 
of .r-ray dermatitis can usually be avoided by the exercise of proper 
skill and care. 

The simpler forms of dermatitis due to .r-rays may often be treated 
successfully with the measures recommended for corresponding phases 
of eczema and dermatitis due to other external causes. Frequently, 
however, even a mild dermatitis due to .r-rays is persistent and exceed- 
ingly painful, and not infrequently is aggravated rather than relieved 
by measures applicable to corresponding grades of dermatitis from 
other causes. In such cases various applications, with or without 
some local anodyne, may be tried. Among those we have found the 
most useful are the following: the lead and opium wash, with or with- 



286 HYPEREMIAS AND INFLAMMATIONS 

out the addition of a powder, glycerin, or boric acid, as recommended 
for the treatment of acute eczema; a mixture of equal parts of this 
lotion and carron oil (made with olive oil); compound stearate of zinc 
powder; a simple ointment containing one or two drachms of ortho- 
form to the ounce. We have found the following paste, recommended 
by Engman, 1 very satisfactory: 

Boric acid, 12 drachms (48.); zinc oxid, starch, bismuth sub- 
nitrate, and oleum olivse, of each 1 ounce (30.); liquor calcis and lano- 
lin, of each 3 ounces (90.); rosewater 12 drachms (48.). The powder 
should be well rubbed up in a mortar and the lanolin added; the olive 
oil and liquor calcis then are mixed and slowly added. When this is 
mixed thoroughly the rosewater is added, and the whole beaten up 
in the mortar into a light, creamy paste. 

The surface should be kept covered with this paste, spread on old 
linen or several thicknesses of gauze. A sheet of gutta-percha tissue 
may be placed over the dressing to prevent evaporation, unless this is 
uncomfortable, as it sometimes i^. to the patient. 

In deep-seated ulcers, which fortunately are seen but rarely, the 
treatment is usually surgical, the necrosed tissue having to be removed 
and the surface covered with skin-urafts. 



PSORIASIS. 

Synonyms. Lepra, Alphos, Psora. Ger., Schuppenflechte. 

Definition. Psoriasis is a chronic, occasionally acute, inflammatory 
disease characterized by reddish-brown, flat papules, or circumscribed 
plaques or areas of varying size, covered with silvery-white, imbricated 
scales. 

Symptoms. — In typical evolution, the papules and plaques of 
psoriasis always are sharply defined from the surrounding skin, some- 
what infiltrated, slightly elevated, and covered more or less com- 
pletely with silvery-white or mother-of-pearl-colored scales, which are 
arranged in thin layers like mica. On removal of the scales, there is 
exposed, in recent lesions, a bright-red surface; in older lesions the 
color is of a duller hue. If the deepest scale, which is often thin, trans- 
lucent, and closely adherent, is pulled or scraped off, there can be 
seen several minute bleeding points, which correspond to the apices of 
papillse beneath. The lesions vary greatly in number, size, shape, and 
distribution, but the type (that of the dry papule or plaque covered 
with scales) always remains the same; so that in uncomplicated cases 
psoriasis is a distinctly dry disease, without vesicles, pustules, or other 
moist lesions. 

The primary lesion of psoriasis is a pinpoint- or pinhead-sized, flat, 
round or oval, sharply defined, slightly elevated, red papule, which 
always at the earliest moment of observation is covered either entirely 
or all but a narrow 7 rim at the border with delicate silvery-white or 

1 Brit. Jour. Derm., 1903, xv, p. 390. 



PSORIASIS 



287 



mica-white scales. The bleeding points produced by forcibly remov- 
ing the scales may be so minute thai they are only visible with the aid 
of a lens. As the lesion grows peripherally, it may become somewhat 

more infiltrated, slightly more elevated, and covered with more abund- 
ant imbricated scales; butotherwise it retainsits original characteristics. 
Larger plaques and areas are all formed either by the gradual increase 
in size of the original papules, or by the coalescence of a number of 
papules or smaller plaques. The small plaques formed by the periph- 
eral growth of single papules are usually round or oval, hut areas 
formed by the coalescence of smaller plaques are irregular in outline. 
As a matter of convenience, descriptive terms have been applied to the 
lesions of psoriasis to denote their size and arrangement. 

Fig. 62 




Psoriasis, generalized and in large plaques. 



Psoriasis punctata describes the disease which occurs in the form of 
small, scale-covered points. Psoriasis guttata indicates that form of 
the disease with lesions approximating the size of drops of water. 
When the patches become the size of small coins, they are termed 
psoriasis nummularis or discoidea. Psoriasis circinata or orbicularis is 
characterized by patches exhibiting activity at the periphery of the 
circle, the centre of which is free from disease; a condition due usually 
to the involution of the centre as the disease extends peripherally. 
The coalescence of spreading circulate patches produces psoriasis gyrata 
and figurata, in which case fantastic figures are frequently produced. 
Psoriasis diffusa indicates that form where the cutaneous surface is 
affected in large areas. When the coil-glands and hair-follicles are 
chiefly invaded, the disease is termed psoriasis follicularis. Areas of 
long persistence, in which the skin is infiltrated deeply and often fissured 
and covered with heavy scales, are designated as psoriasis inveterata. 



288 



HYPEREMIAS AND INFLAMMATIONS 



Fi<;. G3 



Psoriasis rupioides (Cf. Parakeratosis scutularis) indicates a variety 
of psoriasis in which large, conical crusts, marked by concentric rings, 
occur on many patches. 1 

In a given case the lesions may be of fairly uniform size, but more 
commonly, if at all numerous, they exhibit, different stages of develop- 
ment, and therefore van- in size. They 
may be arrested at any stage of growth, 
and persist for months or years as gut- 
tate, nummular, or larger plaques; or, 
by continued extension and coales- 
i ence, form areas covering an entire 
region of the body. Though cases are 
reported in which the surface of the 
entire body is covered, it is rare that 
areas of normal skin cannot bedetected. 
In number and distribution of its 
lesions and in its course psoriasis 
varies greatly. The disease commonly 
begins with one or two small papules, 
which increase slowly in size. In 
ordinary cases new lesions appear 
during the course of weeks, months, 
or years, until there are often from 
ten to one hundred or more patches 
of varying size scattered over the 
body. It is not unusual, however, 
for the disease to remain for years 
limited to two or three coin-sized 
areas, situated commonly over the 
elbows and knees. Occasionally, a 
single patch may persist indefinitely 
without the appearance of others. In 
other instances, but chiefly in recur- 
rences of the disease, a large number 
of punctate papules may appear within 
a few days; and at times even a gen- 
eralized, acute attack occurs. In the 
same individual the number, size, and 
distribution of the patches vary from 
time to time. With many patients the 
psoriatic areas partially or wholly dis- 
appear in summer, only to return in cold weather. In a smaller number 
of cases the disease is worse in summer and better or entirely absent in 
winter. Without the influence of climate or any other known cause, the 
disease may disappear, partially or wholly, for months or years and 
then return. In recurrences of the disease, the lesions do not neces- 




Psoriasis (large plaques). 



Anderson, Treatise on Dis. of the Skin, London, 1887, p. 310. 



PSORIASIS 






sarily correspond in number, size or distribution with those of earlier 
attacks. In acute febrile and other intercurrenl diseases, patches 

of psoriasis may fade or disappear temporarily. 

Involution of a patch of psoriasis begins in the centre, and is recog- 
nized by diminution in the hyperemia and in the scaling. The process 
progresses slowly until no trace of the disorder is left. Temporary 
pigmentation may remain for weeks (on the lower extremities for 
months) after the scaling and infiltration have completely disappeared. 

Fig. 04 



W^^i 




^ 












^Hk'^t 


•VJ|L 




'•" 2? 


K 




i 








BH§jk&4- m .. m 












^^^^HSb ml 




^^K^J^H^^^^H 








HBprW j 




■ 









( reneralized psoriasis. Lesions coalescing in places to form large plaques. 



In distribution psoriasis is, as a rule, symmetrical, but exceptions 
to the rule occur. The sites of preference of the disease are the extensor 
surfaces of the extremities, especially about the elbow and knee, in 
which situation it. is decidedly most common. After these locations 
should be named in order the scalp, the region of the sacrum, the upper 
surface of the chest, the face, the abdomen, and the genitals; more 
rarely the hands and feet. 
19 



290 



HYPEREMIAS AXD INFLAMMATIONS 



Upon the scalp plaques of well-defined contour, covered with thick, 
whitish scales, may mat the hairs, but alopecia rarely results. Often 
a fillet or hand one or two inches in width projects beyond the border 
line of the seal}) over the forehead. When the vertex is bald from 
physiological loss of hair, the patch of psoriasis usually lingers near 
the fringe of hair left at the sides of the head, projecting thence to the 
regions of baldness. On the face the lesions are usually indistinct and 



Fig. Co 




Generalized psoriasis. Guttate and nummular lesions. 



small in size, being displayed over the cheeks, chin, and nose, avoiding 
parts near the mucous orifices. In the genital region, also, the lesions 
are usually small and indistinct, and over the scrotum psoriasis is 
usually complicated by fissures, moisture, and other evidence of acute 
inflammation. 

The hands, feet, fingers, and toes are not often involved, and the 
palms and soles only rarely. We have had two cases in which the dis- 



PSORIASIS 291 

ease was limited to the palm for considerable periods of time before 
the appearance of characteristic lesions on other parts of the body. 

Other writers report similar instances. In many cases the nail- are 
attacked, being thickened, eroded in points, irregularly laminated, 
rigid, brittle, and yellowish-white or dirty-whitish in color. In certain 
cases the nails alone are attacked (Cf. the chapter on Diseases of the 
Nails). On the palms and soles the lesions may show, instead of scal- 
ing, sharply circumscribed areas, in which the horny layer is much 
thickened. Occasionally, bullous lesions develop in these regions. 1 
Through cracking and partial destruction of horny masses, the patches 
may assume a worm-eaten appearance. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called psoriasis Ungues are those of leukoplakia bucealis, or 
"smokers' patches," of syphilitic disease of the mouth, or flat epithe- 
liomata (Hyde). This opinion is corroborated by other writers. 2 
Schiitz 3 reports two cases and refers to others in which psoriasis was 
associated with mucous-membrane lesions. These lesions, however, 
occur with other cutaneous and systemic disorders, and their relation 
to psoriasis is not demonstrable. 

In a patient subject to psoriasis, a local irritation, such as a pin- 
scratch or a mustard plaster, may cause new lesions to appear at the 
site of the irritation. Crocker 4 describes a form of psoriasis punctata 
in which the lesions, though numerous, are limited to the sweat-ducts; 
and another form of punctate psoriasis in which the papules are situ- 
ated about the hair-follicles. 

The amount of scaling varies greatly in different persons and in the 
same individual. Ordinarily, the scales are abundant and thickly 
heaped up over even small areas; sometimes they are sparse over large 
areas. Free perspiration, friction by the clothing, or frequent bathing 
may prevent the accumulation of scales on areas where they would 
otherwise be abundant. Where the epidermis is thin, the scaling is 
less; therefore, over flexor surfaces, near the mucous orifices, and on the 
back of the hand the scaling is less than over the extensor surfaces and 
other regions. The scaling is more pronounced in advanced years. 
The scales may adhere with considerable firmness to the patch, or 
may be shed freely from the surface, in pronounced cases powdering 
the clothing of the patient or the sheets of the bed upon which he 
reposes at night. As a rule, the scales are disposed over the entire 
patch, extending slightly beyond the margin. 

Instead of a lustrous white, the scales may display a dee]) yellowish 
shade; and instead of being imbricated they may form a continuous 
sheet of exfoliated epidermis. When the eruption is disappearing, 
the scales fall, leaving a pigmented or slightly discolored patch of 
integument. 

1 MM. Hallopeau el 1*. Salmon: Psoriasis palmaire avec Soulevements d'Apparence 
bulleuse, Hull, do la Soc. Fran., 1908, p. 243. 
» See, Annal.-s, 1903, iv, 219: and Oppenheim, ibid., L905, s. iv, vi, p. 379. 

:l Archiv, L899, xlvi. p. 433. 4 Diseases of t lie Skin. 3d ed.. p. 361. 



292 HYPEREMIAS AND INFLAMMATIONS 

Psoriasis is essentially a chronic disease, l>nt may present at times 
acute exacerbation, and occasionally begin as an acute process. In the 
acute stages the inflammatory symptoms are more marked, and the 
lesions are of a brighter red color, and not so sharply defined as in the 
ordinary forms of the disease. The scales are fewer in number, thin 
and easily detached, and the sensations of burning and itching may be 
severe. When acute, the papules are usually numerous and punctate, 
and may appear on the face. In other instances, the patches may be 
as large as a small saucer; arc dark- or lurid-red over the whole area; 
and are covered with a more uniformly constituted, thin, squamous film 
or sheet of seinitransparcnt. delicate membrane, through which the red 
glare of the patch beneath i> visible. This condition may be seen also 
in voting persons to whom arsenic has been administered for the relief 
of the disease, with the production of irritative effects. An acute 
attack nia\ conic and go as sneh, but usually it terminates in a chronic 
form of the disease. 

Subjective sensations may be entirely absent in psoriasis, even when it 
is extensive. There is, however, usually slight, but occasionally severe, 
itching. In acute cases burning and smarting are often present. In 
exceptional cases the subjective sensations interfere with sleep and rest; 
otherwise, the disease does not affect the general health of the patient. 

Atypical and complicated forms of psoriasis' occur in which the 
character of the lesions is modified considerably. Rarely the scales 
may be heaped up in the centre in the form of an oyster shell, pro- 
ducing what is termed psoriasis rupioides or psoriasis ostreacea. In a 
few instances, the accumulated scales have assumed the appearance 
of a cutaneous horn.-' Occasionally, sufficient thickening occurs to 
produce a wart-like appearance. These cases are termed jworiasis 
verrucosa (Besnier, Kaposi, and Crocker). The scales may be slightly 
greasy and the surface beneath exhibit a trace of moisture, making the 
diagnosis between psoriasis and dermatitis seborrhoica difficult if not 
impossible. Indeed, the two conditions may be associated. Occa- 
sionally, in moist situations, on the sensitive skin of children, or as an 
effect of local irritation or infection, the patches may be acutely in- 
flamed and indistinguishable from ordinary eczema. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which forms it is difficult to determine whether 
the two disorders coexist, or the one has assumed the features of the 
other. In these cases there may be itching and infiltration of the skin, 
with vesicular and other lesions foreign to psoriasis, and a catarrhal 
discharge. 3 

Cavafy, 4 Kuznitsky, 5 and others report cases in which psoriatic 
lesions, though numerous, were limited to one side of the body. 

1 Beyer, Wien. klin. Wochenschrift, 1901, xiv, p. 805; a review of the subject, with 
classification of reported cases. 

2 Gassmann, Archiv, 1897, xli, p. 357. 

3 Benassi: A description of the causes of moist forms of psoriasis. Giorn. ital., 
1901, xxxvi, p. 427; abstr. in Monatshefte, 1901, xxxiii, p. 460. 

4 Cited by Crocker. 5 Archiv, 1897, xxxviii, p. 405. 



PSORIASIS 293 

The sequelae of psoriasis are, as a rule, nothing more than tran n<»r 
pigmentation, hut cases arc reported in which involution of the lesions 
has been followed by superficial scars (Crocker, Hutchinson), keloid 
formations (Anderson, Purdon, Crocker), persistent, deep pigmenta- 
tion (Crocker), or permanent achromia (Hallopeau e1 Gasne, 1 and 
Rille 2 ). In some cases these unusual sequela? were due, undoubtedly, 
to the treatment. A few instances have been reported by J. C. 
White, 3 Ilartzell, 4 Schamberg, 6 and others in which epithelioma has 
followed verrucous lesions which had developed upon psoriatic patches. 
Some, possibly all, of such changes were due, as suggested by Ilartzell, 
to previous long^continued use of arsenic for psoriasis. The author 
recently studied a case of this type, in which several epitheliomata 
occurred on verrucous lesions in a patient suffering with psoriasis, who 
had taken arsenic for a long period of time. 

When extensive, and especially after persisting for a number of 
years without amelioration, psoriasis may lose its distinguishing feat- 
ures and assume all the characteristics, both clinical and pathological, 
of dermatitis exfoliativa. 

Etiology. — The cause of psoriasis is not known. Sex, social condi- 
tion, and occupation evidently play little or no part in the etiology. 
The disease is common, comprising about 4 per cent, of all cutaneous 
affections repoi ted in America. It occurs most frequently in the second 
and third decades of life, but no age is exempt. It is unusual for the 
first attack to appear after forty-five, and the disease is uncommon 
under ten, and rare under three, years of age. Rille 8 reported a case 
in which the disease appeared in an infant six days old. Other cases 
in infants less than one year old have been reported by Neumann, 
Kaposi, and others. 

Heredity is seemingly a factor in a considerable number of cases, 
in so far as inherited predisposition is concerned; but direct transmis- 
sion of the disease itself by inheritance has not been demonstrated. 
Several careful observers believe that the disease is often hereditary. 
We have seen several families in which the disorder was present in 
three generations. A family history of psoriasis, however, is the excep- 
tion rather than the rule. Engman's 7 report of a psoriasis family-tree 
is interesting in this connection. Knowles 8 found only six family case- 
in hundreds of cases examined, and concludes that psoriasis is not 
hereditary. It is of great rarity in the dark-skinned races. Such 
cases are reported by Dade, 9 Whrfield, and others. 

An early conception of the cause of psoriasis was that it was a cuta- 
neous manifestation of some humor. Gout and rheumatism played 

i Annates, 1898, s. iii, ix, p. 690. 2 Ibid., 1001. s. iv. ii. p.80. 

\nirr. Jour. Med. Sci., 1885, lxxxix, p. 163. 'Ibid., L899, cxviii, p. 265. 

'Jour. Cut. Dia., I'M)?, xxv, p. 26; ibid., 1000, xxvii, p. 130. 
« .lour. Mai. Cut., L890, \i. p. 385. 
■ Jour. Cut. Die., L913, xxxi, p. 559. 

s Jour. Amri. Med. Assoc, 1912, lix, No. 0, p. II.'); abstT. .lour. Cut. Dis., 101.;. \\\i. 
P. .->7. 

1 Jour. Cut. Dis.. 1000, xxvii, p. 207. 



294 HYPEREMIAS AND INFLAMMATIONS 

an important part in this hypothesis. But modern observers, in view 
of the rarity of the association of psoriasis with these disorders, give 
them a small place in the etiology. 

The disease apparently bears no definite relation to any one systemic 
condition. It appears in individuals who are apparently in perfect 
health, as well as in the delicate and those ill of other disorders. Defec- 
tive assimilation and elimination, such as exist in gout, rheumatism, 
and other arthritic disorders, as well as in plethoric and over-fed indi- 
viduals, exercise an unfavorable influence on psoriasis. Associated 
with such conditions, psoriasis is usually indolent in type, but exceed- 
ingly persistent, unless the systemic condition is improved. 

Metabolic disturbances have been attributed as a cause of psoriasis 
by a number of observers. Johnston and Schwartz, 1 in a careful study, 
found no recognizable disturbances in the nitrogen metabolism in cases 
of psoriasis. Brocq and Ayrignac, 1 in a careful study of the urine in 
psoriatic subjects, found no constant results. Schamberg, 8 on the con- 
trary, reported a remarkable instance of nitrogen retention in the 
studies of metabolism carried out in his experimental work. So strik- 
ing was this example that further investigation is being made. 

In the neurotic and poorly nourished, psoriasis is also persistent, 
but usually with more acute symptoms. The disease has been attrib- 
uted to fright, shock, and other neurotic conditions. Acute toxemias 
of various origins have been followed by an outbreak in individuals 
predisposed to the disease. Pollitzer, 4 in his study of the etiology of 
psoriasis (an excellent review of existing theories), concludes that 
rheumatism, gout, neuroses, and heredity are not direct etiological 
factors in the production of psoriasis, but in the present state of our 
knowledge it can neither be denied nor affirmed that they may have 
some bearing on the obscure conditions of the system which render it 
more or less susceptible to this especial infection. 

Polotebnoff 6 is a strong supporter of the nervous origin of psoriasis. 
He believes that psoriasis is one of the multiple symptoms of a vaso- 
motor neurosis, in which the disturbances in the circulation, just as 
they occur in various organs of the body, sometimes extend to the skin. 
The neuropathic hypothesis has many supporters. 6 Weyl 7 believed 
that psoriasis was due to inherited weakness of the nerve-centres that 
regulate the nutrition of the skin, and that the cutaneous lesions were 
the superficial expressions of a central disturbance. 

The parasitic theory of psoriasis is strongly suggested in many ways. 
Syphilis and tuberculosis have both been held responsible for the pro- 

1 Trans. VI. Internat. Derm. Congress, 1907, p. 862. 

2 Annates, 1906. s. iv, vii, pp. 433-460. 

3 Research Studies in Psoriasis: A Preliminary Report, by J. F. Schamberg, John 
A. Kolmer, A. I. Ringer and G. W. Raiziss, Ph.D., Jour. Cut. Dis., 1913, xxxi, pp. 698, 
802. 

4 Jour. Cut. Dis., 1909, xxvii, p. 483. 

5 Derm. Studien (edited by Unna), Hamburg, 1891, Series 2, vol. v, p. 347. 

• 6 Weyl and others, including Besnier, Polotebnoff, Bourdillon, and Kuznitsky, Archiv, 
1897, xxxviii, p. 405. 

7 Ziemssen's Handbook, 1885, p. 247. 



PSORIASIS 

duction of psoriasis. Erasmus Wilson, followed Inter by l(. \Y. Taylor, 
believed psoriasis to be due to an attenuated syphilis, and recently 
Ravogli 1 states his belief that psoriasis is of nervous origin, the under- 
lying cause of the nervous changes being an extinguished syphilis. 

Men/er- believes psoriasis to he a cutaneous manifestation of a latent 
tuberculosis. Schoenfeld 8 and Huebner 4 made studies similar to that 
of Menzer, but could find no connection whatever between tubercu- 
losis and psoriasis. Seller' describes sharply outlined, circular or ovoid 
bodies found deeply in the skin in cases of psoriasis. lie regards these 
bodies as the probable exciting cause of psoriasis. 

Pollitzer 6 believes that psoriasis is most probably due to an external 
microbic infectious agent. Sehamberg, 7 in his study of the question 
of the parasitism of psoriasis, arrives at no definite conclusion as to the 
parasitic cause of the disease. In his research studies in psoriasis 8 he 
states that an unidentified diplococcus X was found in five psoriatic 
lesions and in one blood-culture, and is deserving of further study; also, 
that an ultramieroscopic, mobile, bacillary body was discovered in 
seventeen out of nineteen cases of psoriasis. These bodies, also, are be- 
ing further studied. Aside from these two, the other parasites cultivated 
from psoriatic lesions were discarded. Probably the earliest writer to 
discuss this phase of the subject was Lang, 9 who described a fungus, 
which he named epidermophyton, that he believed to be the cause 
of psoriasis. His findings were confirmed by Wolff 10 and Ecklund, but 
were later rejected by Neisser and others, including Ries, 11 who found 
the bodies described by Lang to be artificial products and not spores. 

Many attempts to transmit the disease by direct inoculation have 
failed, but Bestot 12 apparently succeeded in inoculating himself from 
an infant who had vaccinal psoriasis. 

The fact that psoriasis frequently has followed vaccination 13 and 
other local injuries of the skin has been held by some as an argument 
in favor of the parasitic origin of the disease. Serkowski and Wisnewski 14 
have recently described ultramieroscopic organisms, resembling the 
Paschen corpuscles of variola, in psoriasis. Successful inoculations 
with these organisms are recorded. It has long been known that in 

Jour. Cut. Dis., 1913, xxxi, p. 250. 

2 Deutsche med. Wochensehrift, 1912, xxviii, No. 45, p. 2119; abstr. Jour. Cut. Dis., 
1913, xxxi, p. 127; and ibid., 1913, xxxix, No. 33, p. 1599, abstr. ibid., p. 1055. 

;! Deutsche med. Wochensehrift, 1913, xxxix, No. 30, p. 1446; abstr. Jour. Cut. Dis., 
1913, xxx : , p. 1054. 

4 Ibid., 1913, xxxix, No. 11, p. 505; abstr. ibid., p. 528. 

6 Wien. klin. Wochenschrift, 1910, No. 29, p. 1075; abstr. Jour. Cut. Dig., L911,:xxix, 
p. 363. 

6 Loc. cit. 7 Jour. Cut. Dis., 1909, xxvii, pp. 196 512. 

1 Loc. cit. » Vierteljahr, 1879, i>. '^~>7. 

1,1 Vierteljahr, 1884, p. 337; abst. Annales, 1885, vol. vi, p. 305. 

11 Vierteljahr, 1888, xv, pp. 521,685, 871 (a review of previous reports on the pathology 
of psoriasis, with bibliography). 

\mi.iles, 1901, s. iv, ii, p. 337 (review of the case by Hallopeau. with discussion). 
18 Weinstein, Brit. Med. .lour., 1902, i, p. 271 (rtsumi of 24 eases): also Rioblanc, 
Monatshefte, February, 1896, xxii, p. 195. 
" Nowinylek, 1913, 15.1. xxv; abstr. Archiv, mil, cxvii, p. t *. r - ; 



296 HYPEREMIAS AND INFLAMMATIONS 

psoriatic patients lesions may be developed artificially along the lines 
of mechanical irritation. In this way, figures in the shape of anchors, 
crosses, hearts, etc., have been produced on the skin of psoriatic 
patients, one of whom has been ingeniously photographed by Fox, 1 
of New York. 

The distribution of psoriatic Lesions suggests that the disease may 
be influenced by the exclusion of sunlight from those portions of the 
body covered with the clothing and the hair. Certain it is that in 
exceptional cases only are the hands involved or is the face attacked 
at a distance from the line of the hairs upon the brow and bearded 
region. It is Likewise true that after exposure of the affected areas to 
abundant sunlight, not only when patients are treated intentionally by 
such exposures of the nude body to light in hospitals and in private 
practice, but in occupations which necessitate the same, beneficial 
results often are marked. 

In winter and in cold countries psoriasis is much more prevalent 
than in wanner seasons and climates, k'ayser reports that in the 
tropics the subjects of psoriasis are few, and the SJ mptoms of the dis- 
ease, when they develop at all, are rudimentary, the typical eruption 
being scarcely ever produced. 

Pathology. The pathogenesis and the proper interpretation of 
the histopathologic^] changes in psoriasis are unsettled questions. 
A reference to the theories discussed in the etiology will suggest the 
hypotheses brought forward to explain the changes found. 

The histopathology has been studied by Ilcbra, Kaposi, Bosellini, 
Jarisch, Sclnitx, and many others. All describe changes both in the 
epidermis and in the corium. Observers disagree as to which occur 
first, and also as to the interpretation of the findings. In the epi- 
dermis the epithelial cells are changed in character and in numbers. 
In the corium vascular changes and cell-infiltration are the most im- 
portant. Robinson, 3 who studied lesions in all stages of development, 
Thin, Jamieson, Tilbury Fox, and others believe the process begins 
with hyperplasia of the rete, which is followed by inflammatory 
changes in the corium. Other investigators of the earliest lesions, 
including Crocker and Verotti, 4 believe that the pathological process 
begins as a circulatory disturbance in the corium, and that the epi- 
thelial changes are secondary. 

In the corium the vessels of the papillary layer are chiefly involved, 
and show dilatation and perivascular cell-infiltration, consisting of two 
types of cells: polymorphonuclear leukocytes and small round cells. 
Some infiltration occurs also about the hair-follicles. The papilke 
are greatly elongated, and in many instances the rete overlying the 
papillae is thin, which fact accounts for the bleeding points which occur 
so readily in psoriasis. The rete shows a marked increase, the pegs 

1 Photographic Illustrations of Cutaneous Diseases, New York. 

2 Geneeskumdig Tijdschrift vor Nederlandsch-Indie, 1907, xlvii, fasc. 5. 

3 New York Med. Jour., 1878. 

4 Annales, 1903, s. iv, iv, p. 633 (bibliography of recent literature). 



PSORIASIS 291 

being elongated (acanthosis). The cells are softer, and there i prob- 
ably intracellular edema. The transitional layers are not formed 

in the ordinary case, and cells containing nuclei arc found iii the 
stratum corneum. 

The scales occur as lamellae, and, being loosely held together, arc 
lifted, allowing air to get into the spaces. Leukocytes which have 
migrated from below form small, dry abscesses between the outer 
layers of the stratum corneum. This was first described by Munro 1 
and later by Kopytowski, 2 Bonnet 3 and others. Munro and others 
believe that the leukocytic accumulations above described are the firsl 
changes that occur in psoriasis, and also that this demonstrates the 
parasitic origin of the disease. Sabouraud 4 found similar abscesses in 
pityriasis rosea, and states that many superficial inflammations show 
leukocytes and coagulated serum between the lamellae. 

Diagnosis. — The recognition of a pronounced case of psoriasis is 
made with ease. As usual, it is the atypical form of the eruption that 
awakens doubt. The diagnostic features of the common type are 
summarized in the first paragraph, under the heading of symptoms. 

Eczema. — Eczema elects the anterior surfaces of the body, the neigh- 
borhood of the mucous outlets, the flexor surfaces of the joints and 
limbs, the crevices, folds, pockets, depressions, and protected angles of 
the skin. Psoriasis elects the posterior surfaces of the body, avoids 
the vicinity of mucous outlets, and occurs over the extensor aspects 
of the joints and extremities, especially about the knee and elbow. 
Both disorders occur in the scalp. Eczema commonly spreads down- 
ward over the face, involving the nose, lips, chin, and region back of the 
ear. Psoriasis ordinarily involves only the upper part of the forehead. 

In individual patches eczema will be recognized by its severe itching; 
by the scratching it excites; by the history of moisture, discharge, and 
crusting; by its ill-defined outline; by its asymmetrical disposition, 
except upon the similarly irritated hands and feet; and by the fewer, 
more yellowish, smaller, and less lustrous scales which characterize its 
squamous varieties. In squamous eczema, moreover, the areas are, 
as a rule, larger, more irregular in shape, fewer in number, and the less 
perfectly defined outline does not show the small, round plaques which 
unite to form the larger psoriatic areas. 

Dermatitis Seborrheica. — In seborrhoic dermatitis, the scales are 
smaller, greasy, and less abundant; the surface beneath is moist or 
oily, shows no bleeding points, and is less reddened than in psoriasis. 
The lesions are most numerous on the scalp, over the sternum, and 
between the scapulae, and are rarely found on the elbows and knees, 
from the scalp the disease spreads by choice down behind the ears and 
over the forehead. A fringe may be formed similar to that which 
occurs in psoriasis. The individual lesions and differences in scaling 
arc indicated above. 

1 Annates, 1898, s. iii, ix, p. 961. ; [bid., 1899, s. iii. \. p. 765. 

:1 Lyon Mr<l., L907, fev. 24, p. :;."">(>; abstr. Annates, U>07, s. i\ , viii, p. 704. 

1 .lour. Cul,. Dis., L903, xxi, p. (il. 



298 HYPEREMIAS AND INFLAMMATIONS 

Syphilis. — Psoriasis in many cases greatly resembles the squamous 
and papulo-squamous syphilides. In syphilis the greatest aid will be 
obtained by a history of infection, adenopathy, and mucous patches; 
and in women abortions, miscarriages, and stillbirths. Psoriasis is 
a singularly uniform disease; syphilis is decidedly multiform in its 
manifestations. Syphilitic patches are less symmetrical, more elevated 
at the edge, and the scales with which they are covered are fewer, 
smaller, dirty-yellowish rather than lustrous in color, and are apt 
to form a collarette about the base of the lesion instead of occurring 
in an imbricated maimer over the margin. Their circular outline is 
often abruptly broken by gaps, thus producing semilunar and small 
arc-shaped segments. In syphilis the eruption is less generalized, 
and shares with other syphilodennata the brownish and purplish hues 
of the skin beneath; and the base of the syphilitic lesion is indurated. 
The scales of many of the syphilides which resemble psoriasis partake 
of the character of crusts, being agglutinated by exudations from the 
patch. They are only occasionally squamous as in psoriasis. The 
squamous syphiloderm of the palms and soles often occurs only in these 
localities. Psoriasis is extremely rare in such situations, and is seldom 
limited to these regions exclusively. A psoriasiform circle limited to 
the region of the mouth, nose or chin will generally prove to be 
syphilitic. The disease which has for a long time persisted in the 
production of squamous patches can generally be demonstrated to 
be psoriasis, as syphilis changes its type in the course of months. 

Pityriasis Rosea. In this disease the patches occur most commonly 
on the trunk, rarely on the arms, and practically never in the scalp. 
The patches are more oval than circular, the scales are finer, and on 
their removal no bleeding points are seen. The centre of the patch 
is usually tawny or salmon-colored. The disease is much more super- 
ficial, less inflammatory, and more rapid in its career than psoriasis. 
Complete involution is accomplished usually in a few weeks, and 
recurrences are rare. 

Lichen Planus. — The primary lesions in lichen planus are minute, 
flat, angular papules, which as individuals rarely become as large as 
the cross-section of a small pea. The larger areas are formed always 
by grouping and coalescence of small papules, whereas similar areas 
in psoriasis are produced by peripheral extension of the early papule. 
Instead of presenting distinct scales, the lichen planus papule is covered 
with a thin, horny layer, giving the papule a glazed or varnished ap- 
pearance. There is a tendency to linear arrangement of the lesions, 
and when these coalesce to form larger areas the latter are commonly 
linear or angular in outline. The larger papules and patches in lichen 
planus have a characteristic purplish or violaceous hue, which never is 
seen perfectly in psoriasis. The favorite sites of lichen planus are the 
flexor surfaces of the wrists and forearm and the legs above the ankle. 
It is rarely conspicuous on the elbows and knees and other sites of 
predilection of psoriasis. 



PSORIASIS 299 

Pityriasis Rubra Pilaris (Lrichen Ruber Acuminaius) Is ;i compara- 
tively rare disorder, and lias for primary lesions fine, pointed, scale- 
capped papules, which do not enlarge peripherally, l>ut form larger 
areas slowly by the coalescence of many small papules, some of which 
can be demonstrated at the borders of large areas. The characteristic 
circular areas and typical scales of psoriasis are wanting, and there is 
frequently some impairment of the general health. In exceptional 
instances, however, the two disorders may terminate in a general 
exfoliative dermatitis, in which case it is impossible to state which 
of the two disorders originated the final condition. 

Trichophytosis Corporis. — In ringworm of the body there are, as a rule, 
fewer patches, and these are more distinctly circular. They rarely 
attain the diameter of two inches without showing a clearing centre 
and a slightly elevated border covered with furfuraceous scales. In 
more than half the cases vesicles are present. Subjective sensations 
are usually marked; and, finally, by microscopic examination, the 
Megalosporon ectothrix or endothrix will be discovered, which establishes 
the diagnosis. 

Favus of the Scalp might rarely be mistaken for psoriasis of the 
same region, but the occurrence of sulphur-colored, cup-shaped crusts, 
the lustreless and brittle condition of the hairs, and the presence of 
irregular areas of alopecia or of reddened scar-tissue, with a possible 
history of contagion, and, finally, the demonstration of the AcJiorio?i 
Schonleinii, will insure identification of favus. 

Treatment. — Though it is unusual to see cases in which psoriatic 
lesions cannot be removed temporarily, the disease often returns, and 
is exceedingly resistant to treatment. A method which is successful 
in a given case may fail in the next; and even when it gives prompt 
relief in a given case at one time it may fail utterly in subsequent attacks 
of apparently the same nature. The involution of the disease under 
treatment is, as a rule, not rapid, and a chosen method should not be 
abandoned until it has been given a thorough trial. 

General Treatment. — The general condition of each patient must be 
ascertained and given due consideration in the treatment. There are 
many cases of psoriasis in which the treatment will prove unsuccessful 
until an accompanying systemic disturbance is recognized and given 
proper attention. On the other hand, when the health, habits, and 
surroundings of the patient are normal, it is better to give local treat- 
ment a thorough trial before resorting to arsenic and other drugs which 
are supposed to have a specific action. 

When, as in the anemic, the debilitated, the neurotic, the gouty, 
or the rheumatic, a systemic disorder is demonstrated, the indications 
for treatment are clear. The doubtful cases are those in which, after 
careful study, no definite systemic disturbance is discoverable. Psori- 
asis occurs not. infrequently, and is often especially persistent, in indi- 
viduals who may be classed as fleshy, plethoric, or overfed, without 
other evidences of ill-health. In such cases a restricted diet and 
increased elimination, with possibly the administration of an alkaline 



300 HYPEREMIAS AND INFLAMMATIONS 

diuretic, are effective aids to local treatment. Some writers advocate 
such measures in all cases, unless they are eontraindicated by anemia 
or other conditions calling for increased nutrition of the body. 

As a rule, the diet should be simple and nutritious. In most in- 
stances, meat, sweets, pastries, hot breads, hot cakes, and highly 
seasoned foods should be largely or wholly avoided. Vegetables and 
fruit may be eaten freely. In acute conditions, when the subjective 
sensations are annoying, the diet should be practically that recom- 
mended for acute stages of eczema. Alcohol, coffee, tea, and tobacco 
should be interdicted or used in moderation only. In properly selected 
cases, an animal-free diet is often of great service. Passavant, how- 
ever, claims to have cured himself and others by a. diet exclusively of 
meat. 

The influence of climate 1 in inveterate psoriasis should never be 
ignored. Many patients who sutler from repeated relapses of the dis- 
ease are worst 1 in winter, and are either better or entirely free from the 
eruption in summer. In mild climates, in which the temperature is 
uniformly registered at <»r near a point of maximum comfort for the 
skin, this disease is both Infrequent and less severe, (liven an equable 
climate, many patients obtain prompt relief at the seashore, while 
others improve rapidly under the influence of a dryer atmosphere and 
higher altitude. The majority of patients with psoriasis are, how- 
ever, either unable or unwilling to seek a change of climate for the 
relief of a disease which, at worst, is only an annoyance. In cold and 
changeable climates some patients add greatly to their comfort by 
varying their dress to meet the exigencies of the weather, thus keep- 
ing the skin at as even a temperature as possible. "When there is 
much itching, cotton or linen underwear next to the skin is required. 

Internal Treatment. — Among the remedies supposed to have a specific 
action upon psoriasis, arsenic enjoys the highest rank. In some cases 
prolonged administration of arsenic gives temporary or even perma- 
nent relief. In a large proportion of patients, however, carefully selected 
as fit subjects for this therapeutic agent, it will prove utterly valueless 
even in the most skilled hands. Moreover, it is not possible to deter- 
mine in advance what cases will yield to arsenic; and even with a given 
individual the drug may be of great value at one time and at another 
without effect. Recognizing these facts and bearing in mind its possi- 
ble ill effects, the wisest course is not to employ arsenic at first, but to 
delay its administration in any case until local treatment has been 
given a thorough trial. 

Arsenic is valuable chiefly in persistent cases of psoriasis, in which 
the lesions have ceased to enlarge. It is unsuited for all cases of the 
disease occurring wdth rather acute symptoms, such as those having 
subjective sensations and exhibiting unusually vivid redness of the 
patches. It should not be given when the disease is in process of evo- 
lution; and therefore not in psoriasis punctata and psoriasis guttata, 
unless the lesions have long been limited to patches of the sizes to 
which these names are given. For the same reasons, it is often objec- 



PSORIASIS 30] 

tionable in the psoriasis of the young, for, though the drug is usually 
well tolerated in early periods of life, it is al this time thai the di ea e 
is most often encountered in its progressive stages. 
The following rules for the administration of arsenic are in general 

to be observed: It should be given at first in small doses, which are to 
be increased cautiously. In case toxic effects appear, the dosage 
should be reduced, hut not completely discontinued unless such course 
he imperative. 

Individuals not infrequently possess a marked idiosyncrasy for 
arsenic, and cases are seen also in which its administration for psoriasis 
is followed by acute exacerbation of the disease, with decided aggra- 
vation of the subjective symptoms. A considerable period of time is 
required for arsenic to affect the lesions of psoriasis, and therefore its 
value cannot be tested in any case in less than from several weeks to 
three months' time. The prolonged use of large doses of arsenic has 
been followed in many instances by palmar and plantar hyperkera- 
tosis, and in a few instances by verrucous growths, some of which have 
become epitheliomatous. 1 Continued use of arsenic is capable, also, 
of producing more or less generalized pigmentation, with or without a 
diffuse hyperkeratosis. 

The preparation of arsenic usually employed internally is Fowler's 
solution, the administration of which should be begun in doses of from 
J to 3 minims (0.033-0.2), this amount to be contained in a solution 
of fixed and relatively large dose, such as a teaspoonful of infusion of 
peppermint, wine of iron, dilute syrup of gentian, of orange-blossoms, 
or compound tincture of cardamom with water. When only remedial 
effects are obtained, such as diminution of the scaliness, the dose may 
be steadily continued without change for long periods of time, and 
usually with advantage for some time after the symptoms of the dis- 
ease have disappeared. When, without the production of toxic effects, 
the eruption seems unaffected by treatment, the arsenic may cautiously, 
and always under the direction of the physician only, be pushed until 
10 or more drops of Fowler's solution are administered at a dose. Other 
preparations of arsenic may be used. A solution of sodium arsenite 
is preferred by Stelwagon in cases of weak digestion. Arsenic trioxid 
may be given in doses varying from 4^ to -^ (0.0016-0.0033) grain 
in pill or tablet, or in the form of the Asiatic pill, the formula for which 
is given in the section on General Therapeutics. This pill is less likely 
to be well tolerated than Fowler's solution, but cases are on record in 
which a psoriasis which proved rebellious under other forms of arsenic 
yielded to the Asiatic pill. 

Sodium cacodylate, an organic compound of arsenic containing 55 
per cent, of arsenic trioxid, has been recommended and used largely 
by some French dermatologists. It is supposed to disturb digestion 
less and to be comparatively free from the danger of producing toxic 
symptoms. The dose per oriun recommended is from ] to 3 grains 

1 White, Hartzcll, Schamberg, and others. Loc. cit. 



302 HYPEREMIAS AND INFLAMMATIONS 

(0.033-0.2) three times a day. That it is not safe in Large doses was 
demonstrated by Murrell, 1 who gave a patient 1 grain (0.06) three 
times a day until, on the eleventh day, there suddenly appeared 
serious symptoms of intoxication. Dermatitis following its use is 
reported by Balzer and Griffin. 2 We have seen a diffuse dermatitis 
exfoliativa induced by the administration of sodium cacodylate for the 
relief of psoriasis. For the past few years the usual method of admin- 
istering this preparation has been by hypodermatic injection, giving 
from J to 3 grains (0.0495-0.2). Hartzell 1 has injected atoxyl intra- 
muscularly in the case of eight patients who were psoriatic with appar- 
ent benefit. Enesol has been used by injection in the treatment of 
psoriasis by Sabouraud 1 and Due."' The former obtained good results 
in nine out of twelve cases treated, and recommends the treatment for 
further trial. 

Salvarsan ha- been used to a moderate degree in the treatment of 
psoriasis without success. Pollitzer 8 saw no effect on psoriasis in a 
syphilitic patient to whom he administered salvarsan. Winfield 7 re- 
ports the cure of a case with salvarsan in a patient having a positive 
Wassermann. Trimble, discussing Winfield's case, reported two cases 
of psoriasis, treated by himself and Dr. Fox, which were relieved by 
the use of salvarsan, both patients having syphilis in addition. In 
several cases treated by Trimble no benefit accrued. Several patients 
of our own, having both syphilis and psoriasis, who were treated with 
salvarsan, showed immediate relief of the luetic symptoms, but little 
or no effect on the psoriatic lesions was noted. Schwabe 8 and others 
report similar results. 

Satisfactory results often follow the internal administration of mer- 
CUrous iodid in \ grain (0.013) doses after meals. The remedy is 
given for its alterative effect and not with a view to a suspected 
syphilitic etiology. Phenol and nitric acid, the last-named in the 
largest medicinal doses, are highly extolled by some authors. 

In acute cases, ( rocker advises the use of sodium salicylate and 
salicin. We have found the salicin of value in such cases, in doses 
ranging from 10 to 20 grains (0.66-1.33), three times a day. Haslund 
recommends potassium iodid, increased from the smaller to the largest 
tolerated doses. As many as 600 grains (40.) per diem of the iodid 
have been administered by this method. It is of occasional service. 
The wine of antimony in 5 to 10 minim doses (0.33-0.66); chrysarobin, 
J grain (0.01) rubbed up with sugar of milk, three times daily; and 
potassium bromid and sodium iodid have also been administered 
with reported success. 

In plethoric or rheumatic patients local treatment is often rendered 
more effective by the internal administration of alkalies, such as liquor 

1 Lancet. 1900, ii, p. 1923. 2 Annates, 1897, s. iii, viii, p. 732. 

3 Jour. Amer. Med. Assoc., 1908, li, p. 1482. 

* La Clinique, June 7, 1912, No. 23, p. 361. 

s Ibid., July 5, 1912, No. 27, p. 429. 

6 Jour. Cut. Dis., 1913, xxxi, p. 175. 7 Ibid., p. 493. 

8 Munch, med. Wochenschr., lvii, No. 36. 



PSORIASIS 303 

potassee, potassium citrate or acetate, or sodium bicarbonate, in do « 
of from 10 to 30 grains (0.66 -.), taken with large quantities of water 
three times a day. In the gouty state, with excess of urates in the 
urine, Robinson advises: 



M. 



1} — Potass, acetat., 


5j; 


30 


Spts. sether. nit., 


fgss; 


15 


Vin. colchici, 


iT)i.i; 


8 


Syr. aurantii, 


fSjss; 


45 



Sig. — A dessertspoonful three times daily in water after meals. 



Winfield 1 reports much success in the treatment of psoriasis with 
colonic irrigation and the internal administration of lactic acid. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remember- 
ing that arsenic is superior to them all. Phosphorus, tar, copaiba, oil 
of turpentine, cantharides, eolehicum, and pilocarpin have at times 
a feeble, transitory influence over the patches of the eruption, but their 
employment will disappoint far more than satisfy. The treatment of 
psoriasis by the administration of thyroid extract practically has been 
abandoned as fruitless of desirable results. 

Local Treatment. — The local treatment of psoriasis requires patience, 
care, and a certain degree of skill. In a large majority of cases a remedy 
can be found which, when applied with proper care and persistence, 
will remove the lesions completely. This result, however, does not 
insure the patient against recurrence of the disease. The first indica- 
tion to be met is the complete removal of the epidermic scales from the 
patches. This may be accomplished in various ways. It is prefer- 
able to secure first their maceration in some fatty substance, such as 
one of the oils, or glycerin or vaselin, after which the scales may be 
washed off with the aid of soap and water, the patient being given a 
general bath if the eruption is extensive. After such bathing a salicy- 
lated salve (10 to 20 grains (.66-1.33) of the acid to the ounce (30.) 
of cold-cream salve or Lassar paste) may be applied to the patches 
from which the scales have been removed. If the eruption be local- 
ized, the salve or paste may be spread upon pieces of lint or cotton, 
and thus be retained in contact with the skin by a bandage. The 
scales may also be removed rapidly with a dermal curette, if they occur 
in localized patches. The squamous masses are also removable with 
water alone, as after maceration of the skin in a bath, or after a pro- 
fuse diaphoresis, or even after moderate exudation of sweat, if evapo- 
ration of the latter be prevented by covering the affected part with 
oiled silk or with rubber tissue. Usually, there is no difficulty in 
removing the scales, patients often declaring they can do this without 
assistance. 

Exposure of the skin to solar light is of value in many cases. 
Domenci 2 describes the case of a young man, twenty years of age, who 

'.lour. Amer. Med. Assoc, Augusl 1<), L912, ]>. 416. 

- (Jazz. (1. Osped., 1908; abstr in Derm. Centralb., 1908, xii. p. l">. 



304 HYPEREMIAS AND INFLAMMATIONS 

had suffered with psoriasis for eighteen months. The patient was 
improved after twenty minutes' exposure to the sun's rays. In one 
month the scales ceased to form and at the end of the season he was 
completely relieved. There was no recurrence for one year. We have 
found some patients who could free themselves from the disorder by 
giving the affected parts a sun-bath daily or several times a week. 

Baths play an important part in the subsequent treatment of the 
disease. They may he employed, as by Ilehra, so that the patient 
remains in the water from four to eight hours each day; or he medicated 
by the addition of sulphur, tar, or other substances, so as to combine 
a medicative with a macerative effect. Mongtomery 1 has recently 
emphasized the value of l>;iih> in psoriasis. In private practice these 
baths are much less available than in hospitals. When the eruption 
is generalized and an excessive macerative effect is desired, an under- 
shirt and drawers made of soft rubber cloth may he worn by the patient 
for a few hours each day. By the sweating thus induced it will at 
times he found possible to secure complete disappearance of the 
psoriatic patches. 

In other more obstinate cases, or in those in which for any reason 
vigorous treatment is indicated, as upon the scalp and face, sapo mollis 
may he employed with advantage in t he soap-and-water treatment. The 
linimentum saponis mollis may he rubbed briskly over the patches with 
the aid of a piece of flannel or a sponge, and then immediately washed 
oil' w It 1 1 the oil and scales in a surplus of hot water or left for a time in 
contact with the part. Ilehra and Kaposi employed a species of soap- 
paste, made by rubbing into each patch a small quantity of green soap, 
to which a little water is added until the proper consistency is reached. 
These inunctions are repeated twice daily for six days. The epidermis 
becomes brownish colored, and in three or four days afterward it 
exfoliates in lamella?; then a general bath cleanses the surface. In 
the French hospitals a somewhat speedier method is pursued. On the 
evening of the first day the patient is anointed with green soap, which 
is retained upon the skin during the night. In the morning he takes 
an alkaline bath, and immediately after is thoroughly anointed with 
lard. This course is repeated on the second and third days, after which 
the patient is ready for topical medication of the affected areas. 

For the more obstinate cases, in which exfoliation of the epidermis 
is not readily induced, more energetic measures have been adopted, 
such as the local use of salicylic acid in alcohol, 1 drachm (4.) to 4 
ounces (120.); caustic acid and alkalies; scrubbing the patches with 
stiff brushes, and with clean white sand. 

Once ready for topical medication, the patches may be subjected to 
the local action of the remedy selected for the disease. The choice of a 
vehicle for the application of remedies is a matter of importance. For 
hospital patients, moderately soft ointments, such as lanolin or lard, 
wuth or without the addition of cold-cream ointment, may be rubbed 

1 Jour. Amer. Med. Assoc, October 26, 1912. 



PSORIASIS 305 

into the patches, which may then be covered with cloths pread with 
more of the same ointment. For such cases, an ointment which keeps 
the surface soft and favors penetration of the remedies is usually more 
rapidly effective than the drier pastes, especially when there are much 

scaling and infiltration. When the patches are irritated moderately, 
and in acutely spreading areas, the protection afforded by the paste 
is often of more value than the closer contact of the remedy with the 
lesion permitted by the soft ointment. But the majority of patients 
with psoriasis are unable to give the time necessary for hospital treat- 
ment, and remedies must, be ehosen which will not interfere with the 
usual vocation of the individual. For the scalp and other hairy part-, 
vaselin, or equal parts of vaselin, lanolin, and olive oil, are convenient 
ointment bases. For the face and hands a moderately soft ointment 
may be used as directed above for hospital cases. When the occu- 
pation of the patient will permit, the lesions may be kept covered with 
a thin coating of the same ointment during the day; or this may be 
removed entirely and the patches protected with a tragacanth-varnish 
(see section on General Therapeutics), which in turn must be washed 
off at night before applying the ointment. For covered portions of 
the body, the most convenient base is a paste; equal parts of vaselin, 
lanolin, zinc oxid, and talcum making a good combination. When 
the lesions are few in number, the paste may be spread on a cloth and 
applied. In more extensive areas, the paste may be spread in a thin 
layer over the patches, which then are covered freely with any simple 
powder. This is patted on with the hand or with cotton until a dry 
surface is formed which does not adhere to the clothing. The under- 
clothing next the skin should be of soft cotton. 

For circumscribed areas, flexible collodion, liquor gutta? perchse (trau- 
maticin) holding in solution the remedies to be employed, or medicated 
plasters are more convenient and cleanly than pastes or ointments. 

Salicylic acid, in paste, ointment, or plaster, and in strengths varying 
from 2 to 20 per cent., is often effective, and is free from the disagree- 
able and even dangerous properties of some of the stronger drugs. 
For the face, scalp, and hands, there is no better remedy in the majority 
of cases than ammoniated mercury in 2 to 20 per cent, ointment or 
paste. This remedy is cleanly and usually causes the lesions to 
disappear; but it cannot be used over large areas without danger of 
absorption and constitutional symptoms. 

Chrysarobin, first recommended in the treatment of psoriasis by 
Squire, of London, in 1878, is the most efficient of local applications. 
The drug may be applied in strengths varying from 2 to 40 grains 
(0.13 2.66) to the ounce (30.) of ointment, paste, plaster, collodion, 
or liquid gutta-percha. It is used occasionally in greater strength, 
but with pure specimens it is likely in larger proportions to produce 
disagreeable effects, commonly manifested in a dermatitis of varying 
degree. Even in the strength mentioned above, it is necessary to begin 
its use with caution, testing it by application first to a limited area 
of integument. The dermatitis usually subsides in a few days. A 
20 



306 HYPEREMIAS AND INFLAMMATIONS 

plan followed by us is to have the chrysarobin, whether in liquid, paste, 

ointment, or other vehicle, applied daily until a slight erythema is 
detected at the edge of the brownish discoloration produced by the 
application. Its use is then suspended until the reaction has sub- 
sided. As a rule, the application may he repeated on five successive 
days. In some instances, one single application produces a reaction, 
while in others ten or more fail to do so. 

Chrysarobin should be reserved for the persistent and subacute 1 or 
chronic forms of the disease. When the lesions are numerous or in 
large areas, the most rapid results are obtained by applying the remedy 
in 1 lie form of a soft ointment, 20 to 60 grains to the ounce ( 1 .33 1. to 
30.), which may be rubbed thoroughly into the patches daily. The 
surplus ointment may be wiped oil' and the skin covered with a, dust- 
ing-powder. Used in this way, the drug stains the underclothing and 
the skin and in time produces a dermatitis. For circumscribed areas, 
chrysarobin may be applied in collodion or liquor guttse perdue (trau- 
maticin), in the strength of from 5 to 10 per cent. After the scales 
have been removed thoroughly, a film of this preparation is applied 
with a brush or swab and allowed to dry. The application may be 
renewed daily, as above suggested. An effective combination, sug- 
gested by Fox, is 10 parts each of chrysarobin and salicylic acid, 15 of 
sulphuric ether, and 100 of flexible collodion. Besnier suggests making 
a solution of chrysarobin in chloroform, 20 to 40 grains (1.33-2.66) to 
the ounce (.10. ), which is applied to the patches. The chloroform rapidly 
evaporates, leaving the powder adhering to the surface. This is then 
covered with a layer of traumaticin or collodion. Instead of dissolv- 
ing the chrysarobin in chloroform, it may be mixed with water to form 
a paste and applied in the same manner. Fox tises chrysarobin in a 
o() per cent, aqueous solution of ichthyol. After painting this on the 
patches and allowing it to dry, a dusting-powder may be used. 1 

Hallopeau reports cases in which the lesions disappeared when kept 
covered with unmedicated traumaticin. 

When chrysarobin produces its most brilliant effects, the psoriasis 
patch, previously denuded of its scales, assumes a whitish and normal 
aspect, contrasting strongly with the chocolate or brownish-black dis- 
coloration of the stained skin at the periphery. The patient for whom 
chrysarobin is ordered should be informed of the stain produced on 
his skin and clothing and the possibility of a dermatitis. For these 
reasons it should not be employed on the hands, face, or in the scalp, 
except under unusual circumstances. Novorobin, a derivative of 
chrysarobin, recently brought forward by Schamberg (presented at the 
thirty-eighth annual meeting of the American Dermatological Associa- 
tion, 1914), has the advantage of being more active and less disagree- 
able to use, owing to the fact that the staining qualities are reduced. 

The tars probably rank next to chrysarobin in value in the treat- 
ment of psoriasis. On account of their ability to produce undue reac- 

1 By combining the autoserum treatment with the local application of chrysarobin 
unusually good results have been obtained. 



PSORIASIS 307 

t ions in susceptible skins, it is well to employ them 6rs1 on a relatively 

small portion of the affected surface; and it is necessary to leave the 
medicament on for several hours, as the tars do not in all cases produce 

prompt reactions. Often black pnncta are visible when the tar is 

lodged in the orifices of the cutaneous follicles, simulating thus the 

"blackhead" of the comedo, a condition termed by Ilebra "tar-acne." 

I'ix liqnida, oleum cadinnm, or oleum rnsci may be employed in the 

form of a salve, l drachm (4.) of either to the ounce (30.) of lard or other 
fatty base (lanolin, vaselin). A thin layer of this ointment may be 
painted over or well rubbed into a patch denuded of scales twice 
daily. In Vienna a still more energetic effect is secured by using a soft 
soap freely over the patches while the patient is in the bath, then 
anointing him with tar, and finally returning him to the bath, in which 
he remains from four to six hours. 

For localized eruptions, green soap in combination with tar and alco- 
hol serves a useful purpose, either in the proportion of equal parts of 
the three ingredients or by combining them in other proportions, as, 
for example: 



M. 



Other combinations of service are the liquor yicis alkalinm, the 
formula for which is given in the chapter on Eczema; or Wilkinson's 
salve, as modified by Hebra, the latter combining the remedial effects 
of sulphur, tar, and soap, as follows: 

1$ — Sulphur, sublimat., 

01. rusci (crud. vel. rectif.), aa §ss; 15 

Saponis mollis, 

Adipis, aa 5j; 30 

Cret. praeparat., 9ijss; 3 33 M. 

Sig. — Wilkinson's salve, modified. 

Where the sensitiveness of the skin to the action of tar has not been 
tested, or when the skin is particularly tender, 1 a small quantity of the 
Wilkinson salve may be added to any simple ointment; or Spender's 
ointment of tar (see the section on General Therapeutics) may be sub- 
stituted. Afterward 1 drachm (4.) of the oil of tar, or of oleum nisei, 
to the ounce (30.) of oil of almonds or of alcohol may be employed. 

When toleration is established, the tar may be rubbed over the 
patches in a pure state with a stiff brush, a procedure preferred in some 
parts of Germany, after which the patient either remains for some 
hours in bed, or is powdered with soapstone and bandaged with flannel, 
so that when the clothing is replaced it may not adhere to the tar. 

1 Burnett, J.: Treatment of Psoriasis in Children, Merck's Arch., L908, x. p. 171. 



1$ — Saponis mollis, 




5iv; 


120 


01. rusci., 








Glycerin., 




aa 5j; 


30 


01. rosmarin., 




5jss; 


6 


Alcoholis., 




Oss; 


240 


Sig. — For external 


use. 







308 HYPEREMIAS AND INFLAMMATIONS 

Absorption of any tarry compound applied externally may result 
in general toxic symptoms, including fever, vomiting, diarrhea, stran- 
gury, or the elimination of the toxie agent in secretions which are black- 
ened by its presence. These symptoms are usually relieved in from 
twenty-four to forty-eight hours after the discontinuance of the drug. 

Pyrogallol, first suggested as a remedy for psoriasis by Jarisch, is 
inferior to ehrysarobin. It is used in the strength of 10 per cent, in 
vaselin. It is effective, though less rapid in effect than ehrysarobin, 
is cheaper, is odorless and painless, and it discolors to a less extent 
the sound skin. Both remedies are capable of being absorbed from 
the skin-surface and of producing constitutional symptoms (pyrexia, 
s1 rangury, and blackish evacuations). Even fatal results have followed 
tin' use of pyrogallic acid. 

Beta-naphthol (CioHgO) was first employed in psoriasis by Kaposi. 1 
It may be applied in alcoholic solution. Following the employment 
of a 1.") per cent, ointment. Kaposi reported speedy disappearance of 
psoriatic patches. It does not -tain the skin, hair, or nails. 

Crocker, of London, similarly advised thymol in ointment, 10 to 30 
grains (0.66 -. ) to the ounce (30. ) ; and Williamson advises turpentine, 
2 drachms (8.) to the ounce (.*>().) of olive oil, with the odor corrected 
by the oil of lemon. 

Circumscribed areas have been treated successfully by the daily 
application of compresses wet in a 1 to 300 or a 1 to 200 solution of 
potassium permanganate, 2 or in 70 to 90 per cent, alcohol containing 
2 per cent, of salicylic acid. 1 

For inveterate cases, Unna and Dreuw recommend the following: 



M. 



Blaschko 4 finds Uochard's formula of value in stubborn cases which 
do not yield to ehrysarobin : 

3- 



l\ — Acid, salicylic. 






Sijss; 


10 


C'hrysurobin, 










()1. nisei, 




;ia 


5v; 


20 


Saponia mollis, 










Vaselin., 




a a 


5vj; 


24 


Sig. — For external 


use. 









Iodi pur., 




gr. x; 


166 


Hydrarg. chlorid. mitis, 




gr. xx vj ; 


17 


Vaselin, vel adipis, 


q.s. ad. 


5iij-5ijss; 


100 1 M 



These stronger applications must all be used with caution, and any 
dermatitis produced should be treated with soothing ointments. 

The nitrate, as well as the iodid and oxid, of mercury in the form 
of ointment is applied by many practitioners to patches of psoriasis 
usually few in number and limited in extent. The action of these 
agents, however, is inferior to that of those already named. Other 
articles more recently suggested in the external treatment of psoriasis 

1 Wien. med. Wochenschrift, xxxi, pp. 617, 641, 681. 

2 Hallopeau, Annales, 1902, s. iv, iii, p. 518. 

3 Lau, Semaine med., September 13, 1899. 4 Archiv, 1901, lvi, p. 253. 



/' [R [KERATOSIS SCUTULARIS 309 

are thilanin, which seems to possess some value; hydracetin; cacodylic 
acid; rufigallic acid, l() per cent, in an ointment base; cupric oleate; 
anthrarobin; and gallacetophenol, 5 to 10 per cent, in salve or in 
traumaticin. 

Heimann 1 recommends the use of the Uviol lamp in the treatment of 
psoriasis. 

Radiotherapy is a clean, efficient and most valuable method of local 
treatment in psoriasis. In the majority of instances, psoriatic lesions 
disappear with more certainty and with much greater rapidity under 
.r-rays than with any other local measure. The rays should be em- 
ployed with great caution, and a dermatitis should not he induced. 
Few exposures of moderate intensity suffice. A dermatitis may be pro- 
duced in an area the seat of psoriatic lesions by an amount of .r-rays 
which, if applied to the normal skin, would produce little or no reac- 
tion. Telangiectasia is prone to develop in areas in which an active 
dermatitis has been induced. Recurrence of lesions takes place after 
radiotherapy as after other methods of treatment. Great caution 
is necessary in treating a series of recurrences, especially if the recur- 
rent lesions occupy areas formerly involved. Radiotherapy is not 
recommended in psoriasis of the scalp, on account of the resultant 
alopecia, and should be the method of choice only in selected cases. 

Prognosis. — The permanent relief of a grave case of psoriasis is not 
insured by any treatment, though hundreds of patients are permanently 
relieved by even the simplest measures. The disease often recurs, 
and may do so repeatedly for the greater part of a lifetime. Permanent 
relief, therefore, should be neither promised nor predicted in any case. 
Once relieved, it should be the aim to guard against all possible 
recurrences. It is important to insist that treatment shall be followed 
until the last lesion has been cleared away. If even a few small areas 
are left, recurrence will follow more surely and quickly. After relief 
of any obstinate or recurrent attack, as also in inveterate cases, the 
prognosis is greatly improved by the removal to a climate suitable for 
the psoriatic patient. 

Parakeratosis Scutularis. — Under this title Unna 2 described an affec- 
tion characterized by abnormal cornification, afi'ecting the body in 
areas, and accompanied by superficial inflammation. The lesions are 
described as occurring on the leg in patches the size of a shilling to a 
half-crown or larger, as being livid-red in color, and showing special 
involvement of the hair-follicles. In the follicles are described horny 
balls, which are early yellowish-red in color, later chalky-white, and 
which finally run together and form with the interfollicular scales 
peculiar large, bent shields, one or more of which are placed in the 
middle of the brownish areas. The under surface of the shield is dotted 
with a, large number of thorn-like horny balls, representing the horny 
balls drawn from the follicles. On the scalp the hairs are enclosed 

1 Jour. Cut. I)is., 1911, xxix, p. (YSo. 

- Intern;. t. Alius. L890, Part :?, NO. 8; Bistopathology, p. 286. 



310 HYPEREMIAS AXD INFLAMMATIONS 

in bundles of yellowish-white, waxy, horny frills, which run together 

and form a yellowish-white cap, closely adherent to the head. Weiss, 1 
under the title Parakeratosis ostracea {seutvlaris), described a case with 
lesions closely simulating those above described. In this there were 
scattered over the body-surface discrete, variously shaped, larger and 
smaller, whitish and yellowish, laminated and raised masses. The 
resemblance between the rupioid psoriasis of Mc( 'all Anderson and this 
case was striking (see Psoriasis). It is believed by many that the two 
cases above mentioned are rare and unusual forms of psoriasis. 

PARAPSORIASIS. 

Synonym. Resistant Maculo-papular Scaly Erythrodermia. 

Fox and MacLeod,- in a careful study of a case of parakeratosis 
variegata and a survey of the literature at that time, classed under 
the second title above the following disorders: erythrodermie pityri- 
asique en plaques disseminees | Brocq I ; dermatitis psoriasiformis nodu- 
laris (Jadassohn ; pit \ riasis lichenoides chronica (Juliusberg) ; lichenoid 
psoriasiform exanthem Neisser); and parakeratosis variegata (Unna, 
Pollitzer, Santi). At a somewhat later date, Brocq 8 introduced the 
term parapsoriasis for this group of diseases, and proposed the three 
following divisions: pant psoriasis en gouttes, parapsoriasis lich&noide, 
and parapsoriasis in plaques. This classification includes the various 
manifestations, and presents a clear conception of the group. 

Definition. Parapsoriasis is a rare disease of the skin characterized 
by persistent, red, scaling patches or lichen-planus-like lesions, devoid 
of subjective sensations, and resistant to therapeutic measures. The 
disease, as described in individual cases, varies as to type. A par- 
ticular study of the disorder has been made by J. C. White, 4 C. J. 
White,'' ( 'orlett and Schultz, 6 Anthony, 7 Sir Malcolm Morris and Dore, 8 
Sutton,'' and others in addition to the authors above noted. 

Symptoms. — In all varieties the persistence of the lesions in spite 
of treatment is characteristic. The lesions occur chiefly on the trunk 
and limbs. The inflammatory process is superficial and devoid of infil- 
tration and of subjective sensations. The primary lesion is a macule 
or maculo-papule, often scale-covered, which spreads peripherally. 
New lesions slowly but surely appear, until larger areas become in- 
volved. In this way the guttate, retiform, and patchy varieties are 
produced. A true conception of the disease cannot be had from obser- 
vation of a single case. The individual cases differ from each other in a 
striking manner. The particular features of each must therefore be 
depicted. At present it cannot be stated which variety occurs most 
commonly. 

1 Jour. Amer. Med. Assoc, 1912, lix, p. 343. 

2 Brit. Jour. Derm., 1901, xiii, pp. 319-346, inc. 

3 Annales, 1902, s. iv, iii, p. 433. 4 Jour. Cut. Dis., 1900, xviii, p. 536. 
5 Ibid., 1903, xxi, p. 153. 6 Ibid., 1909, xxvii, p. 49 (literature). 

7 Ibid., 1906, xxiv, p. 455. 8 Brit. Jour. Derm., 1910, xxii, p. 249. 

9 Ibid., 1913, xxv, p. 115. 



PAR iPSORl iSIS 



II 



Guttate Variety (Parapsoriasis en gouttes I Brocq), Dermatitis psoriasi- 
formis nodularis (Jadassohn), Pityriasis lichenoides chronica (Julius- 
berg). In this variety a close resemblance to psoriasis is noted. Again, 
at times, a scaling syphiloderm is simulated. The eruption is very 
superficial, consisting of pinhead- to pea-sized papules, round or oval 
in form, and of an intense, clear-red color. The larger are paler, well- 
defined, and flat, with an occasional central depression. The smaller 
are slightly pointed. Scaling may he quite perceptible, or the papules 
nuiv be devoid of scales. The lesions are somewhat firm, and some 



Fig. 66 




Parapsoriasis. (Fordyce.) 



are follicular. The scratched lesion is red and bleeds but little. The 
scale, when removed, is found to be thicker in the centre than at 
the periphery. New papules or nodules appear here and there as 
the eruption gradually increases. In the beginning there is an areola 
of redness. No subjective sensations are present, and involution of 
the lesions is uncommon. The hands, face, and scalp are usually 
free from attack. 

In a patient presenting this type, studied for some years by the 
author, the primary lesion was a red papule, scale-covered at all 
points. As the Lesion enlarged, in this particular instance, it assumed 



312 



HYPEREMIAS AND INFLAMMATIONS 



a darker hue. The sites of election were the trunk and limbs. The 
patches were from pea- to dime-sized, and remained unchanged for 
long periods of time. At varying intervals, new lesions would develop, 
being light-red at first, later assuming the above mentioned character- 
istics. The lesions were but little influenced by treatment. 

Pick, 1 Civatte, 2 and Milian and Pinard 8 have reported cases of this 
disorder which, on microscopical examination, were found to be 
tuberculides. Civatte surmises that they are all of this nature. 

Retiform Variety (Parapsoriasis lichenmde (Brocq), Parakeratosis 
variegata (Unna i \PoUitzer i Santi), Lichen [variegatus (Crocker). — In 

I w 67 




o 







Erythrodermie pityriasique. (C. J. White.) Section. Low power. Represents the 
section as a whole, with the mosl gravely affected regions of the corium and of the 
epidermis in the centre of the photograph. The great atrophy of the epidermis and 
the disorganized cond.it ion of the corium are well shown. On each side of the photo- 
graph the corium is beginning to appear more normal, and on the left hand the various 
normal deeper structure- are present. Hematoxylin-eosin. 

this variety the eruption is more generalized than in either of the other 
forms, and is represented by lesions that may be described as inter- 
mediate between those of lichen planus and psoriasis. The subjects of 
this disorder have been adults in the third and fourth decades of life. 
The eruption is usually generally distributed over the trunk and extrem- 
ities and is retiform in character, almost as though the patient were 
covered with a net. This peculiar appearance is induced by hyperemia 
occurring in the form of a patchy network, enclosing areas of a less 
intense hue. The primary lesion is a reddish-yellow or darker colored, 



Archiv, lxix, p. 411. 

Annates, 1906, p. 209 (Brocq's clinic). 



Annales, 1907, s. iv, viii, p. 477. 



PARAPSORIASIS 



313 



flat-topped, scale-covered papule. Thelesionson coalescing produce the 

peculiar picture above described. The extremities may be the seal 
of a more marked dermatitis, with increased scaling, and also with 
more distinct papulation, the papules being flat-topped, shining, lichen- 
planus-like. In a few recorded cases, the premycotic stage of mycosis 
fungoides has been mistaken for this eruption. 1 One such case came 
under the observation of the author. This patient for some years 
was considered by experts to be suffering with parapsoriasis of the 
retiform type, but subsequently developed true mycosis fungoides, to 
which he later succumbed. This form of parapsoriasis is resistant to 
treatment. 

Fig. 68 




Erythroderniic pityriasique. (C. J. White.) Section. High power. Represents the 
most severely affected area of the epidermis. The rather increased stratum corneum 
and the marked changes of the other layers are clearly seen. Hematoxylin-eosin. 

Parapsoriasis en Plaques (Brocq). — The cases described under the 
title of Erythroderniic pityriasique en 'plaques disseminees and Xantho- 
erythrodermia yerstans by J. C. White, Crocker and others belong 
to this group. In this variety plaques or patches of varying- size 
and irregular shape occur on the trunk and limbs. The patches are 
well defined, range in size from that of a dime to a walnut or larger, 
and present varying shades of red, reddish- or yellowish-brown or fawn- 
color, and at times a darker brown. In certain cases a seborrhoic 
dermatitis is simulated. Moderate scaling is usually present, and the 
scales are small and adherent. In certain instances visible scaling i> 
absent. On pressure the color may all be removed. r riirrv is no cle- 



1 Jamieson, .lour. Cut. I >■'.*., L901, i». I 10; Hudelol and Gastou, Annates, 1904, 

v, p. L090; and also the first case of 1'ima. 



314 HYPEREMIAS AND INFLAMMATIONS 

vation of the lesion, no infiltration of the skin, and subjective sensa- 
tions are absent. The lesions are very persistent and show practically 
no tendency to undergo spontaneous involution, but are clearly resist- 
ant to treatment. The patches sometimes are so delicate as to appear 
like a mere stain. 

Etiology. — The cause of parapsoriasis is unknown. It is essen- 
tially a disease of adult life, though one patient studied for some years 
by the author, developed the disease at the age of twelve years, and 
at the present time is suffering with active manifestations of the dis- 
order, with l>nt little change after sixteen years' duration. Exposure 
to excessive heat has been given as a factor in some cases. Men are 
more frequently attacked than women. There appears to he no con- 
nection between psoriasis or lichen planus and this disorder. 

Diagnosis. Parapsoriasis is to he differentiated from dermatitis 
seborrheica, psoriasis, lichen planus, the maculo-papular syphiloderm, 
and the premycotic stage of mycosis fungoides. By taking into con- 
sideration the chief characteristics of this disorder as described here- 
tofore the persistence of its lesions in spite of treatment, their super- 
ficial character (being devoid of Infiltration and subjective sensations), 
their gradual c\ olut ion, t heir slow spread, and their location — it may he 
recognized. 

Pathology. The pathogenesis of the disorder is unknown. C. J. 
White 1 suggests that the disease may he (\mv to involvement of the 
deeper arterial twigs, producing a local ischemia, in consequence of 
which the other changes described occur. The histology, as summarized 
by Fox and MacLeod, is as follows: In the corium is found a super- 
ficial inflammatory proce>s, confined to the papillary and subpapillary 
layers, with dilatation of capillaries, edema, and cellular infiltration. 
The epidermis shows interepithelial edema and defective cornifica- 
tion. In the prickle-cells is found a moderate parenchymatous edema. 
Nuclei are present in the stratum corneum. No necrosis is noted, 
and the prickle-cells appear healthy. Corlett and Schultz, 2 in their 
careful histological study, call special attention to the vascular involve- 
ment, which they consider the essential change and the cause of the 
other abnormal histological findings. 

Treatment. — A few cases have undergone spontaneous involution, 
the remainder have been resistant to treatment. All sorts of local and 
internal treatment have been tried, but no method has been proved 
successful. In the plaque variety we have obtained temporary results 
with radiotherapy. Internally, arsenic has been given a good trial, 
and the salicylates and salicin have been used. Locally, the stimula- 
ting treatment recommended for psoriasis may be used in the guttate 
and small-patch varieties. In the widely distributed cases, stimu- 
lating preparations are not recommended. Milder measures, such 
as are recommended for a slight degree of dermatitis, should be 
employed. 

1 Loc. cit. 2 Loc. cit. 



PITYRIASIS ROSEA 315 

Prognosis. As Indicated above, the prognosis is unfavorable a to 

relief of the lesions, hut good so far as the general health of the patient 
is concerned. In a few instances the plaque variety lias been relieved, 
but as a rule the eruption is unaffected by any method of treatment. 

PITYRIASIS ROSEA. 

Synonyms. Pityriasis Maculata et Circinata, Herpes Tonsurans 
Maculosus, Pityriasis Circinata. Fr., Pityriasis rose de Gibert, Pity- 
riasis circine et margine, Pityriasis dissemine, Pityriasis rul)ra aigu, 
Koseole squameuse (Chapard). 

Definition. — Pityriasis rosea is an acute, rarely chronic, self-limited, 
eruptive disease, characterized by superficial scaling patches of vary- 
ing size, usually round, oval, or circulate in outline, having a pale-red 
hue, with often a fawn-colored centre, and situated chiefly on the trunk. 

This disorder was first recognized and described by Gihert, 1 and later 
by Bazin, 2 Horand, Duhring, 3 and others. 4 

The subjects are commonly young adults, but the disease is seen in 
children and those in middle life, of both sexes. The outbreak of the 
malady, in exceptional cases, may be preceded for a variable time by 
languor, lassitude, inappetence, or a feeling of chilliness. Occasionally, 
the first noticeable symptom is the occurrence of mild fever, the body 
temperature rarely rising above 102° F. There may be slight swell- 
ing of the submaxillary or cervical glands. General adenopathy has 
been reported. In acute cases there may be distinct congestion of 
the fauces. In large numbers of cases, how T ever, no constitutional 
symptoms are present. 

In some cases, Brocq 5 believes in all, the general outbreak is pre- 
ceded for a week or ten days by a single lesion, situated usually at the 
side of the trunk. This "primary lesion" may often be recognized as 
the largest, most conspicuous, and most brilliant in hue of all the patches 
which later develop. The eruption often escapes recognition for a 
time after its appearance, on account of its sparseness or the trifling 
degree of itching it arouses. When fully developed, it is characterized 
by the conspicuous appearance over large surfaces of the trunk, espe- 
cially upon the integument covering the clavicles, the ribs, and the 
scapulas, less often on the exposed face and hands, of numerous pinhead- 
to small-coin-sized or larger, circumscribed, roundish or oval-shaped, 
slightly elevated, macular or maculo-papular lesions, which are fitly 
designated by Thibierge as kl medaillons." These lesions may be dis- 
crete, closely set, or confluent, and instead of being elevated may be 
either on a level with the general surface or slightly depressed, with 

1 Trade pratique des Maladies de la Peau, Paris, I860, i, p. 402. 

2 Affections generiques de la Peau, Paris, 1862, p. 365. 
:; Anicr. .lour. Med. Sci., 1880, lxxx, p. 359. 

1 Moingeard, These de Paris, 1889; Chapard, T., ibid., 1885; C. Colcotl Fox, Lancet, 
London, ism, ii, p. 485; Thibierge, Pa Pratique dermatologique, 1902, iii. p. s'.> I (with 

colored plate). 

5 Annates, L887, s. ii, via, p. 615. 



316 HYPEREMIAS AND INFLAMMATIONS 

an annular border. They are dry, covered with furfuraceous, rather 
adherent seales, and vary in eolor from a yellow or tawny (chamois- 
skin shade) to a deep red. The infiltration is slight, and the patch is 
situated superficially. Itching is commonly inconspicuous among the 
symptoms, but in acute and extensive eases may be severe. 

The fully-formed disks vary in long diameter from the width of a 
finger-nail to three or four centimeters or more. G. H. Fox 1 emphasizes 
the fact that extensive inanimate patches may be formed by conflu- 
ence of smaller areas. The oval contour is that more often recognized 
as characteristic of a well-developed lesion, the long axis of the disk 
usually corresponding with the lines of cleavage, and the terminal 
extremities of the oval being slightly frayed by the irregularity with 
which the fine, branny scales are there disposed. The patch fre- 
quently has a tawny salmon shade, which is characteristic* of the 
disease, and enlarges by peripheral extension, leaving a relatively clear 
centre. The scales often have a silvery-grayish color. The eruption 
may be fairly well generalized, but the face and other exposed parts 
of the body commonly escape, though the scalp may be involved. In 
the latter event, the hairs are unaffected. The evolution of the erup- 
tion may be by successive development of the eruptive elements at 
intervals for one to ten weeks or longer. 

The variations exhibited by the exanthem in this affection are dis- 
tinct, but are scarcely ever sufficient to mask the characteristic appear- 
ance of the oval or circular plaques over the neck, the arms, the ab- 
domen, or the extremities; sometimes first appearing over the latter 
and extending thence to the trunk. 

Fox 2 calls attention to the close similarity between pityriasis rosea 
and eczema marginatum of the axilla and groin. Scholtz 3 reports three 
cases illustrating this point. At times a retiform expression is given to 
the picture by coalescence of the patches. The disease occasionally 
occurs in the negro. 4 Wile 5 reports pseudo-vesicles associated with 
other lesions in a case of pityriasis rosea. 

There may be moderate itching, with nocturnal exacerbation, but 
the usual type of the disease is mild. The affection runs its course 
ordinarily in from four to eight weeks, but may last for several months, 
if new lesions continue to appear. Fox 6 believes that there is an acute 
(the common) and a chronic (the rare) type, and quotes a case of Hallo- 
peau's which lasted for four years. Recurrences are rare, though we 
have noted several such instances. Towle 7 and others have reported 
recurrent cases. 

Etiology. — The causes of this disease are obscure. It is without 
question more common in the spring and in autumn than in the other 
seasons. Bazin believed it occurred chiefly in lymphatic and scrofulous 

1 Jour. Amer. Med. Assoc, August 17, 1912, lix, p. 493. 2 Loc. cit. 

3 Lancet Clinic, 1912, cviii, No. 21; abstr. Jour. Cut. Dis., 1913, xxxi, p. 375. 

4 Howard Fox, Jour. Cut. Dis., 1908, xxvi, p. 67; Schamberg, ibid., 1909, xxvii, p. 267 

5 New York Med. Jour., November 13, 1909. 6 Loc. cit. 
7 Jour. Cut. Dis., 1909, xxvii, p. 364. 



PITYRIASIS ROSEA 317 

patients. Mos1 of the patients are young (fifteen to forty years of 
age); ninny arc of the female sex, have lighl hair and delicate skins, 
and have been enfeebled by physical fatigue or overtaxation in school. 
Profuse perspiration has been assigned as a cause by Horand. 

Though no true epidemics are reported and positive evidences of 
contagion are wanting, it occasionally happens that the disease is so 
unusually prevalent during a few weeks in a given locality as to sug- 
gest an epidemic. There are also instances in which two members of 
the same family were affected. 1 Jt is possible that the disorder is 
feebly infectious and allied to the exanthemata. Szoaboky, 2 in 50 
per cent, of 119 cases of this disease, recognized that there was but slight 
febrile movement before the development of the eruption. Of the 
entire number of patients only one had a return of symptoms. After 
microscopic examination, he failed to recognize a parasitic etiology for 
the disease; but in 66 per cent, of cases discovered that there were func- 
tional troubles of different character connected with the nervous sys- 
tem (sweating, trembling, pallor and redness, headache, and exag- 
gerated reflexes). A large number of observers believe the disorder 
to be parasitic, among the earliest of these being Vidal. Oppenheim 3 
recognized double-contoured organisms in the lesions, suggesting an 
oidium, which in one instance appeared to transmit the disease from 
cultures. Mewborn 4 found a fungus with septate mycelium, staining 
with a central granular portion and clear, unstained margins. Dubois 5 
describes a eryptogamic parasite, represented by masses of round 
spores up to 5 microns in size, found within the follicular and glandular 
orifices, which he believed to be etiological in pityriasis rosea. 

Pathology. — The histopathology of the disease has been studied 
by Darier, Vnna, Hollmann, 6 and Sabouraud. 7 The changes begin 
apparently in the papillary body and the subpapillary layer of the 
cutis, and include a dilatation of the vessels, perivascular cell-infiltra- 
tion, and edema. As the disorder progresses, these changes are more 
marked, especially in the perivascular cell-infiltrate. The rete shows 
decided intracellular edema and proliferation of the prickle-cells, espe- 
cially in the interpapillary portions. As the disease approaches its 
acme, minute vesicles (not visible on macroscopic examination) form 
beneath the horny layer, which later is exfoliated. Sabouraud states 
that these vesicles are found in the outer layers of the epidermis, much 
as the "dry abscesses" described by Munro are formed in psoriasis. 
The absence of polymorphonuclears (phagocytes) in the vesicles leads 
him to believe that the disease is not parasitic, but a vesicular ery- 
thema of toxic origin. 

1 Crocker; Zeisler, Jour. Cut. Dis., 1893, p. 494; Fordyce, ibid., p. 497; G. H. Fox, 
and others. 

2 Monatshefte, 19(H), xlii, p. 495. 

3 Verhandlung. der 79 deutsch Naturforscher und Aertze, September, 1907. 
1 Jour. Cut. Dis., 1906, xxiv, p. 431. 

6 Annates, January, 1912, s. v, iii, p. 32; abstr. Jour. Cut. Dis., 1912, xxx, p. 382. 
6 Arehiv, 1900, li, p. 229. 

■ Revue praktique dea Maladies cutanees, syph. e1 ven., June, 1902; abstr., Jour. 
Cut. Dis., 1903, xxi, p. 55. 



318 HYPEREMIAS AND INFLAMMATIONS 

Diagnosis. — The diagnosis is simple, especially if a number of oval 
patches show the usual arrangement, with long axes in the lines of 
cleavage. When the lesions are numerous hut less perfectly developed, 
and are of the smaller, maculo-papular and less inflammatory type, 
the disease may resemble a maculo-papular syphiloderm so closely as to 
deceive even the expert. In the absence of all other evidences of 
syphilis, the delay of a few days will usually permit the development 
of cither the typical oval lesions of pityriasis rosea or of other signs of 
syphilis. In syphilis the elementary macule's are uniformly smaller 
and much less disposed t<> scale. Ordinarily, the lesions of pityriasis 
rosea an- less infiltrated, are of a brighter but paler tint, and are usually 
more rapid in evolution than those of syphilis. The congestion of the 
fauces in the former is of a bright-red color and diffuse, while that of 
syphilis is dull-red and circumscribed. Other diseases to be differen- 
tiated are the following. 

Dermatitis Seborrhoica. In this disease, the slow development of 
the lesions; their distribution over the scalp, sternum, and between the 
scapuhe. rather than on the trunk along the lines of cleavage; the coarser 
and more abundant scales; the fine papules on the one hand or large 
areas on the other; and the absence of the oval lesions of pityriasis 
rosea, will establish the diagnosis. There are cases in which the differ- 
ent ial diagnosis is exceedingly difficult or almost, impossible, and which 
suggest an intermediate stage between the two disorders. 1 

Psoriasis. In psoriasis the patches are infiltrated, elevated, and 
more sharply defined. The abundant imbricated and silvery-white 
scales, the bleeding points beneath, and the distribution of the lesions, 
are points of value in the diagnosis. 

Ringworm. In ringworm of the glabrous skin the lesions are rarely 
so numerous or so symmetrically distributed. The areas are more 
definitely circular, more circumscribed, and often display minute 
vesicles at the periphery. The areas show clearing centres and are 
usually larger than those of pityriasis rosea. Finally, the trichophyton 
fungus can be demonstrated in the scales. 

Treatment. — Pityriasis rosea, as a rule, is a self-limited disease, in 
which the duration and career vary greatly in different cases. Conse- 
quently, it is difficult to judge of the value of treatment in a given case. 
Systemic treatment should be varied to meet the indications in each 
instance. General symptoms, if present, should receive appropriate 
attention. In the major portion of cases no internal treatment is 
required. Crocker believed the course of the disease is shortened by 
giving salicin in 15 grain (1.) doses three times a day. Locally, mild 
sulphur or other antiseptic ointments appear to shorten the duration 
of the disease in many instances. A convenient and simple treatment, 
which we have employed with apparently good results in many cases, 
is as follows; The patient takes a bath at night before retiring, and after 
drying the skin applies to the areas a weak vinegar or dilute solution 

1 Besnier, Annates, 1889, s. ii, x, p. 108. 



> 

< 




DERMATITIS EXFOLIATIV I 319 

of acetic acid, and before this dries follows with a M) to 15 per cent. 
solution of sodium hyposulphite. In a few moments, after the surface 
is dry, a simple dusting-powder may be applied. In the lew instances 
in which itching or burning is annoying, the underclothing should be 
of silk or cotton, and the surface of the body should be kept constant ly 
covered with some adherent powder, like zinc stearate. Occasionally, 
it is necessary to use soothing, mildly antipruritic lotions or ointments, 
such as are recommended for the early stages of eczema. In unusually 
extensive cases, in which itching; is a pronounced feature, mild expo- 
sures to .r-rays are followed by prompt cessation of subjective sensations 
and by more rapid involution of the lesions. 

DERMATITIS EXFOLIATIVA. 

Synonyms. — General Exfoliative Dermatitis, Pityriasis Rubra 
(Crocker), Erythrodermie Exfoliante (Besnier), Dermatite Exfolia- 
trice. 

Definition. — Dermatitis exfoliativa, as the term indicates, denotes 
a general redness of the skin accompanied by scaling. Much con- 
fusion has existed concerning this disease, and many terms have been 
used by various writers to designate particular groups studied. In 
this work the following types will be considered: 

1. Dermatitis exfoliativa (Wilson). 1 This group includes the so- 
called primary type. With these will be included the so-called second- 
ary cases, originally described by Buchanan Baxter. 2 When fully 
developed, these secondary cases are indistinguishable from those of the 
primary type. This type follows such diseases as psoriasis, eczema, 
dermatitis seborrheica, lichen planus, pityriasis rubra pilaris (Devergie), 
and dermatitis venenata, and develops either spontaneously or as the 
result of irritant applications to the primary disease. In this group of 
secondary cases, also, should be placed those produced by the local 
application of hydrargyrum, chrysarobin, and arnica, and possibly also 
those induced by the internal administration of quinin, arsenic, anti- 
pyrin, and antitoxin. 

2. Pityriasis rubra (Hebra), 3 a special type characterized by small 
scales, absence of infiltration, final atrophy, and commonly fatal ter- 
mination. 

'A. Dermatitis exfoliativa neonatorum (Hitter), 4 a special type of the 
disease occurring in infants. 

4. Dermatitis exfoliativa epidemica (Savill), b a type described as 
occurring in epidemics, largely among the poor in homes and asylums. 
The recurrent scarlatiniform erythema 6 is not included in this group, 

1 Med. Times and Gazette, London, 1870, i, p. 118. 
- Brit. Med. -lour., 1879, ii, p. 79. 

3 Diseases of the Skin. The New Sydenham Society Translation, vol. ii, p. 69. 
1 Central Zcits. f. Kinderheilk., 1878, Ed. 2. 

f> On an Epidemic Skin Disease. Brit. Jour. Derm., 1892, iv, pp. 35 iV2 and t'»9-100. 
1 I Virol: Pseudo-exantheme scarlatiniforme r6cidivant. Bull, et Mem., Soc. m6d. dea 
Hup. de Paris, L876, ii, 30; and Besnier. 



320 



HYPEREMIAS AND INFLAMMATIONS 



although it presents many features in common. In certain cases, 
instead of having recurrences, this disease becomes persistent, when 
it might be considered a member of this group (Cf. chapter on Scarla- 
tinit'orm Erythema . 

Dermatitis exfoliativa {Wilson, Brocq). Exfoliative dermatitis is a 
disorder in which, over considerable portions or the entire surface of the 
body, the skin is reddened and covered with lamellated scales, which 
arc exfoliated freely from the surface. The degree of hyperemia varies 

Fio. 69 




Dermatitis exfoliativa. 



in different cases. The redness displayed in the regions affected may 
be a bright crimson, an erysipelatous, or a purplish shade, with some- 
times a faint tinge of yellow. The scales vary in size and in the rate 
of formation in different cases, and are usually thin and papery. They 
are commonly attached at one border and overlap, but in certain cases 
the attachment occurs in the centre. They are usually larger and 
more numerous over the extremities and back than over the neck, 
face, and chest. In the scalp they are usually matted together with 
sebum and form a crust. The palms of the hands and soles of the feet 



PLATE VI 




Dermatitis Exfoliativa. (Fordyce.) 



DERMATITIS EXFOLIATI] I 



321 



are usually affected late in the disease, and sometimes escape alto- 
gether. Here the epidermis peels off in large plates. In the course of 

the disorder the hairs may fall, and in some cases the alopecia is gen- 
eral. r I Tie nails become opaque and dystrophic, and there is USUall) 

thickening of the nail-bed, which pushes the nail upward, with resulting 

deformity. In certain cases the nails are shed. 

The disease commonly begins with redness, upon which desquama- 
tion supervenes. The articular folds of the skin in the genital region 
and the head and trunk are most often the early seat of the disease, 
which may involve consecutively one part after another. The affec- 
tion may be limited to one region, or several distinct regions may be 
involved simultaneously. As a rule, the disorder, beginning in patches, 



Fig. 70 




Primal \ exfcll itne dermatitis. 



spreads rapidly, and in the course of from one to two weeks covers 
the entire surface. At times, constitutional symptoms accompany 
the beginning of the disorder, exhibited as malaise, chills, fever, and 
inappetence, and later recurring elevation of temperature is associated. 
In severe cases the features of the patient may be disfigured slightly 
by tumefaction of the lips, swelling of the ears, and puffiness of the 
eyelids. In most cases the skin is dry, but rarely is moistened with 
pathological discharge. Often there is coincident adenopathy. The 
mucous surfaces of the eyes, nose, mouth, and throat may participate 
in the general disorder and become the seat of inflammatory, and in 
rare cases even of pseudo-membranous and exfoliative, processes. 
The subjective sensations are variable. Itching and burning may be 
21 



322 HYPEREMIAS AND INFLAMMATIONS 

present in all degrees or absent entirely. Chilliness is always a promi- 
nent symptom. 

In the secondary east's, the disease when fully developed is indis- 
tinguishable from that described above. 

The course of the disease is variable; recurrences are frequent, and 
cases are recorded which have lasted for a half-century. 1 In certain 
cases there is rapid loss of strength and weight, although in many the 
genera] health is unaffected. The urine is commonly normal, although 
in certain cases albumin may occur. Its presence is considered of 
grave portent by Morris, Pringle, 2 and others. Tidy, 3 in a study of 
the metabolism in exfoliative dermatitis, concludes that the excretion 
of nitrogen and fluid in the urine is deficient, the excess being excreted 
by the skin, and thai the excretion of uric acid is excessive; hut that 
these changes in the urine are secondary to the changes in the skin. 

Pringle 4 records cases in which the patients became insane, and gives 
insomnia as an important symptom. 

Etiology. Males somewhat outnumber females as subjects of the 
disease, the majority being between twenty and forty years of age. 

The several toxemias, gout, rheumatism, tuberculosis, chronic alco- 
holism, the genera] causes (.f anemia, asthenia, and cachexia, have all 
been cited as etiological factors in the several forms of exfoliative der- 
mal itis, and in cases each of l he causes named has been effective. The 
disease is in many instances prof oundly affected by climatic influences, 
often firsl appearing in the autumn of the year. Local applications 
of hydrargyrum, 6 chrysarobin, and arnica 6 have been followed by 
dermatitis exfoliativa, and it is possible that certain cases following 
the administration of quinin, arsenic, antipyrin, and antitoxin serum 
may he of the same type. 

Pathology. — The histopathology of these affections has been studied 
by Brocq, 7 Vidal, 8 Girode, 9 Tuna, 10 Bowen, 11 and others. The findings 
have been exceedingly variable, due probably to the fact that the 
examinations have been made at different stages of the disorder, and 
possibly also of different types. As a rule, the following findings have 
been noted: a cellular infiltration of the corium, particularly the upper 
part, in certain cases, this being found also more deeply around the 
hair-follicles and sweat-glands; and other evidences of cutaneous 
involvement, such as dilatation of the blood-vessels, and edema, with 
its consequent changes. In the epidermis the changes usually noted 

1 Mackenzie, S: On Dermatitis Exfoliativa Universalis. Brit. Jour. Derm., 1889, 
i, pp. 285-303, inc. A series of 21 cases. 

2 General Exfoliative Dermatitis (Pityriasis Rubra). Debate, London Dermato- 
logical Society, Brit. Jour. Derm., 1898, x, pp. 437-464, inc. 

3 Brit. Jour. Derm., 1911, xxiii, pp. 133-149, inc. 

4 Loc. cit. 

5 White: Jour. Cut. Dis., 1912, xxx, pp. 707 and 708. Case I. 

6 Crocker: Diseases of the Skin, p. 400. Bowen: Jour. Cut. Dis., 1910, xxviii, p. 1 
(a fatal case). 

7 Annales, 1882, p. 534. 8 Bull. Soc. med. des Hop., March, 1882. 
9 Annales, 1888, p. 519. 10 Histopathology, p. 274. 

11 Loc. cit. 



DERMATITIS EXFOLIATIVA 323 

have been parakeratosis and acanthosis. In cases of long standing 
pigmenl deposits arc found in the corium. 

Bowen 1 describes the histology in a typical case of the Wilson type 
as follows: desquamation of the horny layer in strips, with nuclei in 
the cells ( 'para keratosis ) ; collections of leukocytes lying below the horny 
layer; stratum granulosum absent; rete thickened, especially the inter- 
papillary portions (acanthosis); leukocytes between the epithelial cells; 
a sharply differentiated cell, stained with eosin, found here and there 
among the epithelial cells; in the corium vascular dilatation, with peri- 
vascular cell-infiltration in the upper portion of the papillary layer 
(oval and spindle connective-tissue cells, small round cells with large 
nuclei, and a few eosinophils), and elongation of the papillae. The 
sebaceous and coil-glands, collagen, and elastin were normal. 

The pathogenesis of the disorder is not indicated by the histological 
findings. 

Diagnosis. — The disease is to be differentiated from other scaly 
dermatoses. Psoriasis, lichen planus, and dermatitis seborrheica, 
which sometimes develop into dermatitis exfoliativa, can be differen- 
tiated, as a rule, by recalling the distinctive features in each of these 
disorders. It is only in rare instances that they become generalized. 
The selection of particular regions of the body by these disorders, the 
character of the scaling, and their accompanying subjective symptoms, 
are all of diagnostic value. The possibility of a dermatitis exfoliativa 
being the prefungoid stage of granuloma fungoides should be remem- 
bered. 

In more advanced stages of the disorder, the history of recurrences, 
and its special features would be of value in diagnosis. 

From pemphigus foliaceus, dermatitis exfoliativa is distinguished 
by the absence of bulla?, and by the absence in most cases of grave 
systemic disturbance, although there may be stages of pemphigus 
foliaceus which present all the characteristics of a dermatitis exfoliativa. 

From pityriasis rubra (Hebra) it is distinguished by the history in 
the latter of steady progression without remissions; the universally 
reddened, scaling epidermis, without infiltration; the ultimate atrophy 
of the skin; the not infrequent ulceration and gangrene; and, finally, 
the serious systemic conditions — all classic features in pityriasis rubra, 
not commonly found in such combination in dermatitis exfoliativa. 

Treatment. — As at least some cases are due to a toxemia, the gen- 
eral condition of the patient should be investigated thoroughly and 
treatment instituted to meet indications. Crocker, 2 Mook, 3 Engman, 
and others report favorable results after the treatment of dermatitis 
exfoliativa with quinin in large doses. The tolerance in the cases 
reported by Mook was remarkable. As high as 85 grains per day 
were given without producing cinchonism. Arsenic is not recom- 
mended, except in rare instances. The internal treatment should he 
directed toward meeting any indication suggested by the general 

1 Loc. cit. 2 Loc. cit. 3 Jour. Cm Dis., L908, xxvi, p. 408. 



324 HYPEREMIAS AND INFLAMMATIONS 

condition. Jaborandi, pilocarpin, and aspirin may give relict', and 
occasionally arc of value. The patient should be given complete 
rest, preferably in bed. Formerly applications were used to relieve 
itching and to keep the skin softened. The dry treatment, as sug- 
gested by Fngman, 1 appears to give good results. With this treat- 
ment the patient is simply kept covered day and night with a 
dusting-powder. For the first day or so. this is uncomfortable, but 
later becomes perfectly comfortable and involution of the lesions occurs 
more rapidly. In case oily or greasy preparations arc found necessary, 
the simple ungucntuni aquse rosse, U. S. P., will be found useful; 
or Hebra's ointment, 1 part to 1 of vaselin, with from 5 to 10 grains 
(().:{:; 0.66) of salicylic acid to the ounce (30.) of the whole, is usually 
grateful to the skin. An ointment often employed with great advan- 
tage in these cases over the entire cutaneous surface is: 



T$ — Sulphur, precipil .. 

Acid, salicylic, fift gr. ijss ; 

Bale. Peru., ill. \; 

Ungl . petrolat .. 

Ungl . ;i<|. roe., an .*> — : 15 



166 

liii 

M. 



Other simple ointments and oils, with or without the addition of small 
amounts of salicylic acid, phenol, ichthyol, tar, or other remedies, 
may be of value. As a rule, mild preparations arc more serviceable 
than the stronger remedies. One of the combinations of lime-water, 
olive oil, and zinc-oxid described in the treatment of eczema is occa- 
sionally of service. Emollient, starch, and hot baths are generally 
comfortable to the skin. 

Prognosis. — In the majority of instances, the patient eventually 
recovers, though convalescence is protracted and delayed by frequent 
recurrences. A small proportion of cases progress to the formation of a 
universal exfoliative dermatitis, from which the patient rarely recovers. 
In grave and protracted cases, the general health of the patient suffers, 
and a fatal result may be expected. Bowen 2 reports seven cases, with 
a fatal issue in five. 

Pityriasis Rubra (Hebra type) . — Synonyms : Dermatitis Exfoliativa. 
Fr., Pityriasis rubra aigu. — Pityriasis rubra is a rare, chronic, and 
usually grave inflammatory cutaneous disease, involving, as a rule, 
the entire surface of the body, in which the skin, usually without 
infiltration, becomes deeply reddened and covered with fine scales. 
There is commonly no subjective sensation save that of chilliness, and 
the later symptoms, the sequelae of the affection, are : shedding of the 
hairs, adenopathy, pigmentation, atrophy, and, as a consequence of 
pressure and friction effects, ulceration. The cutaneous manifesta- 
tions are probably but symptoms of a systemic disease, which in the 
majority of cases terminates fatally. 

Symptoms. — The disease is characterized by a superficial hyperemia 
and inflammation of the skin, declared in patches or by a diffuse red- 

1 Quoted by C. J. White, Jour. Cut. Dis., 1912, xxx, pp. 705-715. 2 Loc. cit. 



DERMATITIS EXFOLIATI] I 325 

ucss of a vivid or lurid tint, and by an abundance of small, lamellated, 
bran-like scales, which arc continuously exfoliated from the epidermis 
throughout the course of the malady. Patients rarely present them- 
selves for observation until a considerable portion of the body-surface 
is involved; but Kaposi states that in two patients observed by him 
the disease was first noticed in the neighborhood of the articulation-, 
lucre is no vesiculation, pustulation, moisture, or crusts. The palmar 
and plantar surface's are usually less distinctly reddened than the face 
and the extremities, having at times even a pallid hue, hut they always 
present scaling. 

Under pressure with the diascope, the redness subsides or assumes a 
yellowish shade; while, as a rule, when the integument is gathered up 
between the finders and thumb, no infiltration can be recognized. 
Exceptions, however, have been noticed by several observers. 1 The 
temperature of the skin is slightly increased. The exfoliation, as the 
disease progresses, is one of its most striking characteristics, the scales 
accumulating in large quantities in the clothing of the patient, who is 
engaged, as a French writer has it, in the labor of stripping himself 
involuntarily of his epidermis. 

The disease persists for months or for years, being always more severe 
in expression as it advances, the scales being shed more abundantly, 
leaving a smooth, shining, occasionally purplish, or even cyanotic, 
skin. In the patients observed by Jamieson 2 the skin was so dark- 
hued as to suggest the color of a mulatto. Gradually the patient 
becomes conscious of an increasing sense of chilliness, as though de- 
prived of sufficient body-covering. Usually this is the only subjective 
sensation. Various grades of itching occur in certain cases, or there 
may be instead sensations of stiffness, burning, and tingling. Later, 
the integument seems to retract, as though it were insufficient to encom- 
pass the body, and becomes subject to fissure from extension and con- 
tact, while the lower extremities may be edematous. This retraction 
may he so marked that ectropion of the eyelids may ensue, the fingers 
may remain semiflexed, and wide opening of the mouth may become 
difficult. The skin over bony prominences becomes thin, stretched, 
and often fissured, or becomes the seat of superficial ulcers or gangrene. 
Thinning of the skin of the soles of the feet may render walking painful 
or impossible. The hairs and the nails lose their lustre and become 
friable, and the hairs often fall, though the nails may escape. 

The influence of this epidermal exfoliation, involving, as it does 
finally, every portion of the body-surface, does not fail toward the end 
to he felt by the vital forces. Alternating chills and febrile processes, 
pneumonia of a low grade, colliquative diarrhea, tuberculosis, sub- 
cutaneous abscesses, bedsores, and even gangrene of the skin, may 
close the 1 scene. 

Ilebra and Kaposi altogether had under observation twenty-one 
patients affected with pityriasis rubra, who, with a single exception, 

1 Pityriasis rubra: Chicago Med. .lour, and Examiner, February, L881. 
- Edinburgh Med. .Jour., L880, xxv, p. 879. 



326 HYPEREMIAS AND INFLAMMATIONS 

died from its effects. Cases have been reported in America by G. H. 
Fox, Duhring, Elliot, 1 Bowen, 2 Montgomery and Bassoe, 8 Mook, 4 
Wallhauser, 6 and others. We have had under observation several 
typical instances of the affection. 

The disease is one of early or middle life, and affects preeminently 
the male sex. The progress of the disease is slow, lasting for years, 
though in a few instances it has proved rapidly fatal. The time re- 
quired for extension to the entire surface 4 of the body varies from a few- 
days to two years or more, but averages from three to eight months. 
From the first, the tendency of the disease is to progress slowly to a 
universal atrophy of the skin. Involution of areas, or improvement 
of the cutaneous symptoms, is very unusual. The sweat may or may 
not be secreted in the eourse of the disease. The tongue is bright- 
red iii the early stages; later it is covered with a brownish coat. It 
occasionally undergoes exfoliation. Rhagades may form, especially 
in the palmar and plantar regions. The chief systemic symptoms 
recorded ;irc: languor, chilliness, and even severe rigors, alternating 
with febrile temperatures of recurrent type; albuminuria, diarrhea, 
pulmonary edema, icterus, interstitial pneumonia, bronchitis, rheu- 
matism, and tuberculosis. 

Etiology. The causes of the disease arc unknown. Petrini and 
Jadassohn 6 showed that many cases were tuberculous. 

A case of pityriasis rubra of the Hebra type reported by Mueller, 7 
accompanied by tuberculosis of the lymphatic glands, was more fully 
described, after the death of the subject, by Fabry, 8 who concludes, 
after recognition of the existing tuberculosis, that the contention of 
Jadassohn and Doutrelepont respecting the tuberculous character of 
a large proportion of similar cases requires further confirmation. 
Halle 9 is doubtful as to the existence of tuberculosis in a similar case 
reported by him. It must be conceded, however, that tuberculosis 
occurs frequently in cases of pityriasis rubra of this type. In Elliot's 
case 10 general tuberculosis was demonstrated post-mortem, and he be- 
lieves it to be secondary to the cutaneous disease. This view, with 
regard to many of the cases, was held by Montgomery. 11 

Pathology. — Tschlenow 12 states that the primary changes occur in 
the epidermis, producing secondary inflammation in the cutis, which 
ultimately leads to complete atrophy of the skin. Hebra and Fleisch- 
mann discovered coincident pulmonary, intestinal, or cerebral tuber- 
culosis. Kaposi described an atheromatous condition of the arteries. 
Myelitis was discovered post-mortem in one case by Jamieson, who 

1 Jour. Cut. Dis., 1897, xv, p. 35. 2 Ibid., 1902, xx, p. 548. 

3 Ibid., 1906, xxiv, p. 298. 4 Ibid., 1908, xxvi, p. 408. 

5 Jour. Amer. Med. Assoc, July 6, 1912, p. 10; abstr. Jour. Cut. Dis., 1912, xxx. p. 645. 

6 Pityriasis rubra of Hebra and its relation to tuberculosis (an exhaustive study, with 
bibliography and histology): Archiv, 1891, xxiii, p. 941, and ibid., 1892, xxiv, pp. 85, 
273, 463. 

7 Archiv, 1907, Ixxxvii, p. 255. 8 Ibid., 1908, xci, p. 85. 
9 Ibid., 1907, lxxxviii, p. 247. ,0 Loc. cit. 

11 Loc. cit. 12 Archiv, 1903, lxiv, p. 21. 



DERMATITIS EXFOLIATIVA •">-'< 

has I )<v 1 1 followed by others in the recognition of central iii id peripheral 
neurotic alterations. Kopytowski and Wielowicyski 3 described cocci 
which they think are factors in producing the disease. The histology, 
as revealed in the researches of Hans Ilebrar demonstrates that in 
the earlier period of the disease there is an infiltration of the intern- 
ment, moderate in degree, succeeded at a later period by ciitaiic<>u> 
atrophy, in which the rete and papillae of the corinm disappear. The 
connective-tissue elements undergo sclerosis; and the glands and fol- 
licles of the skin are destroyed. Pigmentation is abundant. Petrini 
and Jadassohn 3 reported inflammatory infiltration of the papillary and 
subpapillary layers of the eorium, a proliferation of the connective- 
tissue cells, and secondary changes in the epidermis. 

Diagnosis. — Many eases reported as instances of pityriasis rubra 
really belong to some other division of the dermatitis exfoliativa group. 
By recalling the characteristic symptoms, namely: the long duration, 
absence of infiltration, fineness of desquamation, the later atrophy of 
the skin, and ultimate fatal termination, a picture is presented that is 
characteristic and very different from psoriasis, eczema, and other 
disorders of this type. 

Psoriasis rarely extends over the entire surface of the body, but at 
times it is generalized. In these exceptional forms a long history of the 
occurrence of typical psoriatic patches may be usually obtained; while 
the bleeding surface beneath the scales and the character of the latter 
will point to the true nature of the disease. Psoriasis occurs frequently 
in healthy, pityriasis rubra in cachectic, constitutions. 

Extensive erythematous or squamous eczema, apart from other 
symptoms, can be recognized at once by the excessive distress occa- 
sioned by the eruption. In every case of generalized eczema, at one 
point or another, there always will be a surface which weeps. In the 
early stages of pityriasis rubra, the patient is not distressed with his 
disorder, but may have a listless expression. The scales are not scanty 
and adherent; they are abundant and exfoliate freely, and there is 
no history of moisture. 

In its early periods, pityriasis rubra can be distinguished from pem- 
phigus foliaceus by the absence of bulla? and of the intolerable stench 
which is often emitted by the sufferer from the latter disease. When, 
however, there is present merely a generalized exfoliative dermatitis, 
the two disorders may well nigh be indistinguishable. 

Treatment. — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are recorded of fatal results after the admin- 
istration of this drug in large quantities for long periods of time. 
Kaposi records a single patient relieved by the use of phenol internally. 
Thyroid extract has been suggested. 

A roborant treatment, including the employment of cod-liver oil, 
iron or qninin, is generally indicated. Quinin, as recommended by 

1 Beitrag. zur. Klinik und Pathologischen Anatomie der Pityriasis Rubra: Axchiv, 
1901, Ivii, p. 33 (bibliography to date). 
- Vierteljahr, 1876, Beft. 1, S. 508. Loc. cit. 



328 HYPEREMIAS AND INFLAMMATIONS 

Engman and Mook, has been given a trial by us in some cases. The 
dose was progressively increased from the medicinal quantities usually 
given to 50, 60, or even 90 grains a day, care being- taken that no ill 
effects occurred relative to the heart or ears. The tolerance of the 
drug was in all cases distinct and improvement marked. 

Locally, the simplest are the best measures. Unguentum aquee 
rosse, I . S. I'., petrolatum, lanolin, diachylon ointment, and vari- 
ous oily creams may be employed. In certain cases the continuous 
bath gives temporary relief; in others the dry treatment with dusting- 
powder suggested for the ordinary type of dermatitis exfoliativa is 
advised. The clothing should be ample and non-irritating, and the diet 
selected with a view to supporting the strength. 

Prognosis. r riic majority of all cases of pityriasis rubra of the Hebra 
type have terminated fatally. 

Dermatitis Exfoliativa Neonatorum | Keratolysis Neonatorum, l\it- 
ter's Pis, (isc). Under this title Hitter v. Rittershain 1 describes a rare 
exfoliating disease of the skin in nursing infants from six days to five 
weeks old, occurring most commonly in foundling asylums. The dis- 
order begins usually as a reddened, exfoliating patch, most frequently 
on the lower part <>l' the face, though it may appear first on any part 
of the body, and rapidly spreads until the entire surface is reddened 
and exfoliating. In some instances vesicles and bullae appear early, a 
fact which led Kichter and others to cla>> the disease with pemphigus 
neonatorum. The angles of the month and the mucous outlets of the 
body frequently show fis>ure> and are covered with crusts. Often 
the mucous membranes of the month, nose, and conjunctiva are in- 
volved. The surface of the skin beneath the scales is red, usually dry, 
and often excoriated. Occasionally, the surface is moist and crusted. 

The duration of the disease varies. In most eases there is complete 
involution in from seven to ten days, with few or no constitutional 
symptoms. Severe cases may last a month or longer, with disturbance 
of the digestion and assimilation, and production often of marasmus. 
Pneumonia is of frequent occurrence. As the result of secondary infec- 
tion, furuncles and abscesses are common; gangrene and sepsis may 
follow. When healing occurs, it is accomplished as a simple and gradual 
diminution of the erythema and cessation of the scaling. Recurrences 
are not uncommon. 

Etiology and Pathology. — Ritter 2 believed in its pyogenic origin. 
In two cases studied by Hedinger 3 the Staphylococcus pyogenes aureus 
was recognized on bacteriological examination, and the author con- 
cludes that dermatitis exfoliativa of the newborn is merely a malignant 
variety of the pemphigus of infants. Kaposi considered it an exagger- 
ation of the normal exfoliation of the newborn. Brocq 4 suggests that 
certain cases described as Ritter's disease may have been examples of 
pemphigus, and states that Behrend regards it as analogous to pem- 

1 Central-Zeitung f. Kinderheilk., 1878, Bd. ii, and Vierteljahr, 1879, vi, p. 129. 

2 Loc. cit. 3 Archiv., 1906, lxxx, p. 349. 
4 Le Traite elementaire de Dermatologie pratique, ii, p. 254. 



DERMATITIS EXFOLIATIVA 329 

phigus foliaceous of Cazenave. Caspary 1 considered it a form of epi- 
dermolysis. Histological examinations 2 show merely a superficial 
inflammation, often with free exudation and excessive exfoliation of 
the epidermis. Skinner' sums up his histological findings as follows: 
Dilatation of the blood-vessels in the corium and hypoderm, edema of 
the prickle-cell layer of the epidermis, and the lifting up en masse of the 
horny layers of the epithelium from a rapid exudation of serum, tending 
to collect in lakes. Hazen 4 describes a high leukocyte count (45,000) 
and the finding of the Staphylococcus albus in fresh vesicles. 

Diagnosis. — Dermatitis exfoliativa neonatorum is likely to be con- 
fused with pemphigus neonatorum, and rarely with general exfoliative 
dermatitis due to syphilis. The differentiation between the first two 
is difficult, and, in fact, the former appears to be a variety of pem- 
phigus neonatorum so called, the latter having recently been proven 
to be an impetigo of streptococcic origin. From a general exfoliative 
dermatitis associated with syphilis it may be differentiated by other 
signs of syphilis which are usually present. A close resemblance between 
the two has been noted by the author. 

Treatment. — The nutrition of the child should be sustained with 
proper feeding, and the warmth of the body maintained. Locally, the 
surface should be kept covered with a soothing oil or soft ointment, 
and great care should be taken in changing the dressings not to damage 
the sensitive skin. 

Prognosis. — The prognosis is unfavorable, as about 50 per cent, of 
the infants affected with the disease die, the outcome depending largely 
upon the strength and vitality of the child. 

Epidemic Exfoliative Dermatitis (Epidemic Skin Disease (Savill), 
SamlVs Disease). — During the summer and autumn of 1891 an epi- 
demic disorder with cutaneous symptoms developed in several London 
asylums, infirmaries and hospitals, affecting about 500 patients. The 
disease was studied with special care by dermatologists and other 
medical men. The brief sketch given below is based upon an excellent 
monograph, with colored and photographic illustrations, by Savill, 5 
on various communications made on the subject in the columns of the 
British Medical Journal and the London Lancet for 1892, and on the 
description given by ('rocker in his treatise. American cases have 
been recorded by Fordyce, 6 and Winfield. 7 

The disease occurred in two distinct clinical types : one with catarrhal 
exudation from the skin, resembling the moist forms of eczema; the 
other dry and non-discharging, resembling pityriasis rubra, and, 
according to Crocker, indistinguishable from that disease. 

The eruptive features were apparently not preceded by prodromata, 

1 Vierteljahr, L884, p. 122. 

- Winternitz, Axchiv, L898, xliv, p. 397; Luitheln, ibid., 1899, xlvii, p. 323; and Mrafiek's 
Handbuch, Bd. i, p. 757 (full bibliography). 
* Brit. Jour. Derm., 1910, xxii, p. 75. 

4 Jour. Cut. Dis., 1012. xxx, p. 325. 5 Loc. cit. 

•Jour. Cut. Dis., 1897, p. 141. * Ibid., 1898, p. 73 



330 HYPEREMIAS AND INFLAMMATIONS 

but gastrointestinal disturbance (vomiting, diarrhea), and in some 
cases sore throat, either preceded or accompanied the appearance of the 
dermatosis. Except in patients of advanced years, there was usually 
post-occipital and cervical adenopathy, not to be explained as sym- 
pathetic with a cephalic eruption. The regions most frequently in- 
volved were the upper limbs, the scalp, and the face; the lower limbs 
less frequently. 

The skin lesions were pruritic, and were irregularly grouped, acumi- 
nate papules, with a follicular site. The face and upper extremities 
were more extensively invaded than the lower extremities. 

The stages of the exanthem, as given by Savill, were: 

(a) A papulo-erythematons stage, lasting from three to eight days, 
in which shot-like papules could be felt beneath the skin. These were 
discrete, and seated on a reddened, thickened, even an indurated or 
edematous, integument. In some cases the onset was in the form of 
marginate and circular nodose patches, resembling those seen in ery- 
thema nodosum. A tew cases resembled ringworm, the flattened 
papules enlarging to a circinate annular group, with minute central 
vesicles, which were readily ruptured. 

(b) An exudative stage, lasting from three to eight weeks, in which 
macules, vesicles, or papules soon formed a confluent eruption, the 
skin being of crimson line, thickened, and scaling in Hakes or in lamel- 
lated crusts in consequence of the exudation. In the moist type the 
papules developed to vesicles with exudation; in the dry type the 
exfoliation occurred in pure scales, pints of which, in some cases, 
could be collected from a patient's skin in a day. In other cases this 
exfoliation was in the form of an impalpable powder. This was 
characteristic of all well-marked cases. 

(c) A stage of subsidence, in which the disease proceeded to involu- 
tion, leaving the skin at first indurated, polished, and brownish in color. 
In many cases the new skin was raw and parchment-like, smooth, shin- 
ing, and readily fissured, resembling in this respect ichthyosis. In a 
few instances, ectropion resulted, as a sequel of conjunctivitis. In 
severe cases the hair and all the nails were shed. Complications 
occurred with pneumonia, gangrene, and albuminuria. A few of the 
attendants upon the sick (children and patients of somewhat older 
years) were attacked; but for the most part the patients, and especi- 
ally those succumbing to the disease, w T ere individuals of advanced 
years of both sexes, inmates admitted for the management of other 
disorders to the institutions in wdiich the disease prevailed. 

Etiology and Pathology. — The cause of the disease was not satis- 
factorily determined. Savill and Russell 1 isolated a diplococcus from 
vesicles and scales which resembled the Staphylococcus pyogenes albus, 
but differed culturally, in that it did not liquefy gelatin, and experi- 
mentally in its effect on inoculated animals. Its etiological impor- 
tance is not settled. 

1 Brit. Jour. Derm., 1892, iv, p. 105. 



PITYRIASIS RUBRA PILARIS 331 

Echeverria 1 described the histology, laying stress on the presence 
of ;i peculiar change in the nuclei of the prickle-cells (peridiaphania), 
which he considered pathognomonic. The remainder of the changes 
described were in the main those found in a superficial dermatitis, 
including cellular infiltration in the cutis, hypertrophy of the rete, and 
parakeratosis with scaling. 

Treatment. Treatment, on the whole, was unsatisfactory. Local 
parasiticides were beneficial to a degree. Crocker recommended the 
treatment employed in other cases of dermatitis exfoliativa. 

Prognosis. — There was a mortality of from 5 to 13 per cent., death 
resulting from exhaustion, with the usual signs of subsultus, shallow 
respiration, and coma. 

LICHEN RUBER. 

Under the term Lichen Ruber, Hebra 2 was the first to describe the 
disease which corresponds closely to the disorder described in these 
pages as pityriasis rubra pilaris. Most of Hebra's cases, however, were 
associated with grave systemic conditions, and twelve out of fourteen 
terminated fatally. Kaposi later described a lichen ruber acuminatus, 
which he stated is identical with the lichen ruber of Hebra, though in 
his cases the general health of the patient was not seriously affected, 
lie divided these cases into tw T o groups, the acuminate and plane. Con- 
fused with these cases were those described by Wilson as lichen planus. 

The relationship of the various diseases under consideration has 
been the subject of much discussion. At a dermatological congress 
held in Vienna, in 1S92, a patient was exhibited who, Kaposi stated, 
was suffering with lichen ruber acuminatus, while Vidal, Hallopeau 
and other Frenchmen declared it to be a case of pityriasis rubra pilaris. 
Critical comparison of the literature and illustrations of the subject 
remove all doubt that pityriasis rubra pilaris (Devergie) and lichen 
ruber acuminatus (Kaposi) are one and the same disease. Hebra's 
lichen ruber, judging from Kaposi's statements and from two plates 
published by Hebra (to which Crocker calls attention), was probably 
a severe form of the disease. A few German authorities still teach 
that pityriasis rubra pilaris is wholly distinct from lichen ruber, which 
they subdivide into lichen ruber acuminatus and lichen ruber planus. 
Instances are cited by Kaposi, Neumann, and others in which the 
acuminate and the plane papules coexisted in the same individual. 
These few cases are probably coincidences or modifications of usual 
types, and lichen planus is generally held to be an entirely independent 
disease. 

PITYRIASIS RUBRA PILARIS. 

Synonyms.— Lichen Ruber (Hebra); Lichen Ruber Acuminatus 
(Kaposi); Lichen-Psoriasis (Hutchinson); Pityriasis Pilaris (Devergie). 
Fr., Pityriasis rubra pilaire. 

1 Brit. .lour. Derm., L895, vii, pp. 9 16. 

2 Diseases of the Skin, Now Sydenham Society translation, L868, p. 57, 



332 



HYPEREMIAS AND IXFLAUMATIONS 



Definition. — Pityriasis rubra pilaris is a chronic, mildly inflamma- 
tory, exfoliating disease of the skin, in which the characteristic lesions 
arc fine, acuminate, firm papules situated at the mouths of hair-fol- 
licles, and displaying at the apex a horny plug or scale, which dips into 
the follicle. By coalescence the papules form reddened, scaling areas, 
which may spread and cover the entire surface of the 1 body. This 
affection has been described chiefly in France by Devergie, 1 Besnier, 2 
Richaud, 3 Brocq, and others. The Museum of the St. Louis Hospital, 
Paris, is provided with illustrations in wax of every phase of the malady. 



Fig. 71 




Pityriasis rubra pilaris. 

Numerous examples of the disease have come under the observation 
of experts in America. The malady is undoubtedly identical with 
lichen ruber acuminatus of Kaposi. 

Symptoms. — The disease usually begins insidiously, but may appear 
more or less suddenly, with or without mild systemic disturbance. 
As a rule, the characteristic papules ("projecting cones") are not seen 
until after a period in which the disease appears as a seborrhea sicca 
of the scalp, with or without palmar and plantar scaling patches. The 
disorder may appear first on the face (nose, brow 7 , lips, chin), as a 



1 Traite pratique des Maladies de la Peau, 1857, 2d Ed., p. 454. 

2 Annales, 1889, s. ii, x, pp. 253, 398, 485. 

3 These de Paris, 1877. 



PITYRIASIS RUBRA PILARIS 






fine pityriasis, or as a condition simulating seborrhea sicca. A similar 
fine desquamation may be present on the cars, neck, and other parts 
of the body before the appearance of papules, but as a rule the hitter 
appear on one or more regions soon after the first evidence of the dis- 
order and gradually extend to other portions of the body. The scales 
are seated at the follicular orifices; are thin, whitish, grayish, or heaped 
up in large discoid masses; are dry, firmly attached, friable, and in 
cases suggest the "crackle-ware" of the potteries. The disease is 
usually well marked over the extremities and on the hack of the neck, 



Fig 




Pityriasis rubra pilaus. 



hut may involve any or all portions of the body. Occasionally, in 
the acute type of the disorder, a large number of isolated papules 
appear somewhat suddenly over several regions, producing a condition 
simulating goose-flesh. 

The characteristic papules are minute, acuminate, hard, dry, and of 
a color varying from that of the normal skin to the different shades 
of pink, rosy-yellow, or duller hues. They are situated at the hair- 
follicles and each is pierced by a hair. At the apex of the papule, and 



334 



// YPEREM IAS AM) I X FLA M M . 1 TIOXS 



surrounding the hair, is a horny sheath, which penetrates the hair- 
follicle for a short distance. Fine lanugo-hairs which pierce the papules 
may he recognized on close inspection; the whitish, horny plugs then 
giving the lesions a scale-capped appearance. 

The papules become more and more numerous, and appear at times 
to coalesce, hut may form patches, at times symmetrically disposed, 
covered with fine elevations, conical and discrete; or they may become 
round, flatter, and coalesce so completely as to he lost in the general 
scaling, exfoliating, erythematous, and lucent area. The yellowish-red 
or deep-reddish patches may he the seat of pityriasic scaling, or may 
exhibit separation of the epidermis in large, adherent Hakes, which, 



Fro. :;; 




Pityriasis rubra pilaris. 



especially over the elbows and the knees, present the appearance of 
psoriasis. When the infiltration is moderate, the intensifying of the 
natural lines of the skin is a conspicuous feature. The areas are 
irregular in size and shape, but frequently have an angular or oblong 
outline. Commonly at the borders of these patches are found the 
initial papules of the affection, still isolated and surrounding charac- 
teristic stumps, filaments, or black points of hairs, enabling one thus 
to make the diagnosis with ease. 

When discrete papules are grouped closely, and in areas formed by 
aggregation rather than by complete coalescence of the papules, a 
"nutmeg-grater" effect is produced when the finger is passed over 
them. At times the eruption is generalized; when the face chiefly is 



PITYRIASIS RUBRA PILARIS 335 

involved, the slight crusts formed are decidedly of the type of those 
described under dermatitis seborrhoica. In many cases the tension 

of the dry, infiltrated skin produces ectropion of the lower eyelid. 
Occurring over the hairy seal}), the accumulated scales and crusts may 
form a dense and resisting cap, which is difficult to remove. The nails 
are usually grayish, yellowish, transversely striated, and roughened. 
There may also be a coincident polytrichia. Important for purjx 
of diagnosis are the little horny, blackish, conical papilla? occupying 
the site of the hair-follicles on the dorsal surfaces of the first and second 
phalanges of the fingers. These usually remain distinct even when, on 
all other parts of the body, their identity has been lost in the general 
exfoliative process. Sometimes an exceedingly characteristic feature 
of the disease is displayed in the face, which on inspection seems 
to be covered with a more or less firmly attached, irregularly creased, 
mortar-like plaster, the "cast" being conspicuously evident on the 
tip and root of the nose, the lower brow, the lips, and the chin. When 
the palms and soles are involved, they become the seat of a firm, thick, 
lamellar hyperkeratosis, reddish-yellow in hue, furnishing a ''kera- 
todermic sandal" (Besnier) for the sole. 

The course of the disease is usually chronic, irregular, and subject 
to relapses and to unexpected exacerbations. The disease has a 
tendency to become generalized, and even universal, and to persist 
indefinitely. Periods of remission or of complete clearing of the skin 
are noted in a few 7 instances, but the disorder usually returns. Of the 
score or more cases that have come under our observation, in five only 
have we seen the skin become entirely free from evidences of the dis- 
order, though in most of the cases improvement was noted for varying 
periods. Of the five cases, one, a rather severe case, has now remained 
w r ell for four years. In tw r o, after periods of freedom from the disease 
varying from a few months to five years, the cutaneous symptoms 
recurred, but not in severe type. In the other two the disease was 
acute in its onset, becoming almost universal within ten weeks from 
its appearance. In one of these patients, who acquired syphilis soon 
after the appearance of pityriasis rubra pilaris, the latter disappeared 
entirely in five months from its onset and had not recurred at the end 
of nine years, when the patient died as the result of an accident. The 
other was entirely relieved at the end of nine months, but his subse- 
quent history is unknown. 

Subjective sensations may be entirely absent, though there is usually 
a sense of dryness and of contraction of the skin. There may be more 
or less itching, though, as a rule, this is not marked. In the earlier 
stages, at least, the general health appears to be unimpaired, even 
when the disorder is generalized. Eventually, however, in some cases 
there is more or less failure of general nutrition, leading in rare instances 
to a fatal result. 

Etiology. The cause of the disease is unknown. It commonly 
begins in the second decade of life, but has been observed in all ages. 
somewhat more often in men than in women. Cases are reported at 



336 HYPEREMIAS AND INFLAMMATIONS 

the age of one and one-half years, 1 two and one-half years,- and at three 
years. 3 

Milian 4 regards tuberculosis as the etiological factor. De Beurman, 
Bith, and Heuyer 5 report four eases in one family, two males and two 
females, the ages ranging from twelve to twenty-eight years, three of 
them having apical phthisis. 

Pathology. — The definite pathogenesis of the disorder is unknown. 
The theory of its being a toxic process due to the bacillus of tuber- 
culosis or other such agent has been advanced. The histopatholo^y, 
as given by Jacquet in Besnier's cases/ Taylor, 7 Heidingsfeld, 8 llart- 
zell, 9 Heller, 10 and others, shows that the papule which is the essential 
lesion of the disease is formed by a hyperkeratosis of the superior por- 
tion of the hair-follicle, and that there is a hyperkeratosis of the entire 
epidermis in addition, and a mild inflammatory process in the corimn, 
probably secondary to the epithelial changes. German cases, under 
the name <>f lichen ruber acuminatus, have been studied by Hebra, 
Kaposi, Neumann, Biesiadecki, Joseph, and others. Different reports 
vary considerably, depending, probably, upon the age of the lesions 
examined. The pathological processes correspond closely to that 
described above, except for a more pronounced inflammation in the 
corimn, as the result of which Kaposi and others believe the epithelial 
changes to be secondary to an inflammation of the corinm. 

Diagnosis. The disease Is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, of a 
hair. In extensive cases of long standing the identity of the papules 
may be lost in the general desquamation over most of the body; but in 
uearly all cases lesions can be recognized on the backs of the fingers, 
as described above. 

From lichen planus the diagnosis is not difficult in the early stages, 
or when individual papules are found bordering the larger areas. The 
d nil-crimson or violaceous hue of patches of lichen planus is character- 
istic. Moreover, the disease is rarely so generalized as pityriasis rubra 
pilaris. Keratosis pilaris is limited, as a rule, to the regions which it 
chiefly affects, the extensor faces of the limbs. Ichthyosis is com- 
monly congenital, the first lesions developing soon after birth. In 
psoriasis the characteristic silvery-white, imbricated scales, the bleed- 
ing points beneath, and the larger size of the primary lesions w T ill usually 
establish the diagnosis. In pityriasis rubra (of Hebra) the history of 
the disease, the absence of distinct papules and of infiltration, and the 
appearance later of atrophy of the skin are distinctive features. It 

1 Whitehouse, J., Jour. Cut. Dis., 1912, xxx, p. 482. 

2 Rasch, Centralb., 1899, i, p. 199. 

3 Heller, Zeitschrift, 1903, x, p. 153 (with histological study). 

4 Annales, 1906, s. iv, vii, pp. 1067-1075. 

5 Ibid., December, 1910, p. 609; abstr. Brit, Jour. Derm., 1911, xxiii, p. 165. 

6 Loc. cit. 7 New York Med. Jour., January 5, 1889, p. 1. 
§ Jour. Cut. Dis., 1906, xxiv, p. 371. 

9 Stelwagon's Diseases of the Skin, 7th Ed., p. 234. 
10 Loc. cit. 



LICHEN PLA VUS 

musl be remembered thai rarely pityriasis rubra pilaris may terminate 
in a generalized exfoliative dermatitis, which cannot be distinguished 

from the same process arising in psoriasis, eczema, or other scaling 
affections (see Dermatitis Exfoliativa). 
Treatment. Systemic treatment should be varied to meet the 

indications in each individual. In many cases tonics, cod-liver oil, and 
an especially nutritions diet are indicated. Crocker praises thyroid 
extract, beginning with 5 grains (0.33) and gradually and continuously 
increasing. Arsenic lias given excellent results in some cases, but in 
a large number has failed; and apparently in a few instances has 
aggravated the disorder. We have had marked amelioration of the 
symptoms following the combined use of arsenous trioxid, grain _,',, 
(0.0033), and protiodid of mercury, grain J (0.01), three times a day, 
together with external applications. 

The local treatment corresponds closely to that of psoriasis, squamous 
eczema, and other exfoliative conditions. The daily use of an oint- 
ment containing from 5 to 20 grains (0.33-1.3) of salicylic acid to the 
ounce (30.) of vaselin, or of equal parts of vaselin, lanolin, and olive 
oil, is often of value in keeping the skin soft and relieving the itching 
when present. For markedly thickened areas, ointments containing 
salicylic acid in strength of 20 to 60 grains (1.33-4.) or more to the 
ounce (30.) may be used; or some of the preparations of ehrysarobin, 
resorcin, oil of cade, or ichthyol recommended for the treatment of 
psoriasis. Fatty crusts, when these are abundant, are to be removed 
by shampooings, as in seborrheal affections of the scalp. 

Prognosis. — The prognosis is unfavorable with respect to the cuta- 
neous manifestations, as in those eases in which the disorder disappears 
temporarily it almost invariably recurs. The tendency of the disease 
is to persist indefinitely. The general health may be unimpaired, but 
is affected sooner or later in many instances. The issue in exceptional 
cases may be fatal. 

LICHEN PLANUS. 

Synonyms. Lichen Ruber Planus, Lichen Psoriasis. 

Definition. — Lichen planus is an inflammatory dermatosis, in which 
are displayed multiple, small, flat-topped, angular or polygonal papules, 
often exhibiting a color containing various shades of crimson or purple, 
the plane apex of each being usually Hat or depressed and covered with 
a horny film. This disease was first described by Erasmus Wilson, in 
1869. The disorder is of frequent occurrence, though it is not one of 
the common diseases of the skin. It is usually chronic, but may be 
acute, and, although in most instances limited in distribution, it may 
be extensive and even generalized. 

Symptoms. In a typical case of lichen planus, the primary lesions 
are pinpoint- to pinhead-sized, angular or polygonal, Hat papules. 
These are sharply defined and covered, not with a scale, but with a 
thin, transparent, horny filament, which gives to the Lesions a waxy 
or varnished appearance. As the papules increase in size, they retain 



338 



HYPEREMIAS AXD INFLAMMATIONS 



their angular or polygonal outline and remain flat, or may become 
slightly umbilicated. The bases are angular or rounded and the sides 
precipitate. The greatest diameter attained by any individual papule 
is about one-half that of a small split-pea, hut by coalescence the 



Fig. 74 




Lichen planus. 

original lesions may form larger areas, which are also angular, linear, 
or polygonal in outline, and are sharply defined from the surrounding 
skin. On the patches the thin, horny covering may he partially broken 
up into fine, closely adherent scales. The color of recent lesions is a 



Fig. 


75 


^ ^| 


■■ 



Lichen planus. (Fox.) 



bright crimson, that of the older a purplish or reddish purple. On the 
surface of the papules may be seen on close inspection minute whitish 
points and lines, to which Wickham has called attention ("Wickham's 
strise"). When the eruption is plentiful, the violaceous color is char- 



LICHEN PLANUS 

acteristic, and the peculiar shining or glistening top observed when 
viewing the lesion in a position where the Light falls aslanl upon the 
surface is also characteristic. As the lesions grow older, the shade 
deepens to a dull purplish or darker color. Involution of the papules 
often leaves a pigmentation of a smoky, sepia, or even blackish, hue, 
which is naturally most conspicuous and most persistent on the lower 
extremities. Occasionally, white, atrophic-looking spots are left, which 
ultimately disappear. 

The lesions may be discrete and isolated, or irregularly grouped, 
but when numerous they tend to multiplication and aggregation and 
form irregular, linear, angular, or polygonal patches, with sharp out- 
lines. Annular or circinate patches may occur. Rarely combinations 
of lines and circinate groups form exceedingly odd-looking figures — 
parallel lines, cockades, scaling crests, rings, or rosettes. The shape 
of the patch may be determined by an external irritation, such as a 
scratch-mark. 

When the papules coalesce and lose their identity, a crimsou-hued 
sheet or mask of the skin is seen, generally characterized not merely by 
the color of the lichen planus papules, but also by a silvery sheen, due 
to thin, shining scales, which do not completely cover, but which sup- 
plement, as it were, the empurpled patches beside and over which they 
form. The scales are not freely shed from the surface, but are attached 
firmly. When there are decided sheets of infiltration, they are most 
conspicuous over the flanks and anterior part of the trunk; but they 
may also be seen elsewhere, as, for example, over the extremities. When 
the patch is undergoing involution, the scaling ceases, the infiltration 
subsides, and a pigmentation somew r hat similar to that described in 
connection with the papules follows. 

The disease, though usually limited to a few regions, particularly the 
flexor surfaces of the wrists and forearms, and the legs immediately 
above the ankles, is symmetrical as a rule, but may appear on one side 
only of the body and may cover large areas, and, in rare instances, the 
entire surface. The disease is seldom seen on the face or scalp, and is 
unusual on the palms or soles. 1 The nails may be involved and present 
lesions similar to those seen in psoriasis and eczema. 

The greatest variation is experienced in the way of subjective sen- 
sations. Itching may be moderate or severe. In acute generalized 
cases the suffering of the patient is extreme. The eruption of lichen 
planus, however, is scratched much less often than that of other 
cutaneous diseases characterized by itching. 

The course of the disease is chronic, and when untreated it may last 
for months or years, either through persistence of the original papules 
and areas, or, what is more' frequent, by the successive appearance 
of new lesions. Occasionally, the disease disappears spontaneously, 
but its tendency is to persist. The disorder may recur, but recurrence 
is an exception to the rule. 

1 Dubreuilh and LeStrat, Annates, L902, s. iti, in, i>. 209. 



340 HYPEREMIAS AND INFLAMMATIONS 

Occasionally, lichen planus may begin as an acute exanthem and 
become generalized in a few days, or even within twenty-four hours. 
In such cases the lesions are usually minute, of bright color, and exhibit 
no tendency to definite grouping. There may be coincident febrile 
symptoms and mild systemic disturbance, or severe concomitant dis- 
orders, such as pemphigus, diabetes, syphilis, and grave ulceration. 1 
These acute symptoms may develop in an individual previously free 
from all evidences of lichen planus, but more commonly in those 
who have exhibited for months or years one or more areas of the 
disease, which then may run an acute course of a few weeks, yielding 
readily to treatment, or may persist as a generalized or localized 
chronic form. A Dumber of variations from the usual clinical types 
occur. 2 

Vesicles at the summit of some of the papules and bulla* occur in a 
number of cases of lichen planus, most frequently in patients who have 
been taking arsenic, but also in others who have taken no arsenic 
prior to the appearance of the lesions. Trautmann 8 has described a 
case in which pemphigus appeared to follow an attack of lichen planus. 
Whitfield, 4 in presenting a patient, analyzed 17 previously reported 
cases, in 9 of w hich the patient had taken qo arsenic prior to the appear- 
ance of the bulla*. He states that the presence of bullae apparently 
has no bearing on the severity or prognosis of the disease. Ilartzell, 5 
Allen, 6 and others report similar cases. 

Lichen planus IS of rare occurrence in children. Crocker, Liveing, 
and Colcott Fox 7 all report a spurious form, which the author first 
named believes to be a subsiding stage of papular or vesicular miliaria 
rubra. The lesions in children differ in no essential from those found 
in adults. 

Occasionally, the lesions of lichen pilaris seu spinulosus (Crocker) 
are found in association with those of lichen planus in certain cases. 

As a rule, the general health is not involved, save when the itching 
is so severe as to interfere with the patient's sleep or rest. Crocker 
refers to generalized cases in which the health was affected profoundly, 
a few of which terminated fatally. In this country one such case has 
been reported by Fordyce. 8 It may be that the severe systemic dis- 
orders present in some of these cases were independent of the lichen 
planus. 

Lesions of a different type from those depicted above, occurring 
with the ordinary types as well as independently, and which are now 
admitted to be forms of lichen planus, have been described under 
various titles. 

1 Johnston, Jour. Cut. Dis., 1907, xxv, p. 86; Galloway, Brit. Jour. Derm., 1906, 
xviii, p. 66. 

2 Crocker, Brit. Jour. Derm., 1900, xii, p. 421 (with discussion before the London 
Dermatological Society). 

3 Zeitschrift., 1906, p. 317. 4 Brit. Jour. Derm., 1902, xiv, p. 161. 
5 Jour. Amer. Med. Assoc, July 20, 1907, p. 225. 

e Jour. Cut. Dis., 1902, xx, p. 260. ' Brit. Jour. Derm., 1891, iii, p. 201. 

s Jour. Cut. Dis., 1899, xvii, p. 56. 



LICHEN PL i \ cs 341 

Lichen Planus Hypertrophicus 1 Is a special form occurring usually on 
the lower extremities, occasionally on the upper, in which the lesions, 
after long persistence, have lost their ordinary characteristics and 
formed thickened, elevated patches. The patches, which are of vary- 
ing size, may be rounded, elongated (hand-like), or irregular, and 
present a reddish-brown or purplish color. They are covered with 
fine, adherent scales and horny projections, giving the lesions a warty 
appearance (lichen planus verrucosus). At times acuminate or conical 
horny papules occur, which by coalescence produce large patches. 
Commingled with these are sepia-brown pigmented spots, and at times 
atrophic areas. Itching is severe and persistent, and the lesions are 
aggravated by the trauma inflicted by scratching. 

Lichen Planus Obtusus is a term applied to a form in which rounded 
or oval, flat or slightly convex papules of large size (pea to bean or 
larger) occur, situated chiefly on the arm or forearm. These may 
occur independently or in association with the ordinary types. 

Lichen Planus Linearis. 2 — The tendency of lichen planus papules 
to form linear groups or bands may be exaggerated to produce this 
type. In such cases a narrow fillet of typical lesions may extend from 
the heel to the trunk along the line of the sciatic or other nerve, or, 
more frequently, from the buttock to a few inches below the knee. 
Such a case has been under our observation. A similar arrangement 
of the lesions may occur along the course of the nerves of the upper 
extremity or on the trunk. Again, the bands may be absolutely 
straight and apparently independent of the course of any nerve. 
Galloway 3 has reported a striking example of this type, and we 
have had a similar case, but less extensive, on the outer surface of 
the thigh and leg. 

Lichen Ruber Moniliformis is a title given a rare form of the disease, 
described in 188(i by Kaposi. 4 Howe, Dubreuilh, Gunsett, 5 and others 
have reported similar cases, in which numerous node-like masses are 
arranged in lines and bands resembling a necklace of beads, with flat- 
tish, punctiform papules, and macules of a sepia-brown hue between 
the nodes. (A case of lichen ruber moniliformis was shown by Dr. 
Hyde before the Chicago Dermatological Society in the year 1903.) 

Lichen Planus Annularis is that form of the disease in which the 
papules, while extending peripherally, leave a clear or clearing centre, 
and form thus circular patches in thin rings or bands, at times coal- 
escing in polycyclic outlines. The patches may be tew or numerous; 
the rings faintly or very distinctly outlined; the component parts 
of the ring, the characteristic papules of lichen planus, either readily 

1 Fordyce, Jour. Cut. Dis., 1897, xv, p. 49; Corlett (quoted by Fordyce, loc. cil )\ 
Lieberthal, Jour. Amer. Mid. Assoc, January 11, 1902, p. 93 (histology); Ravogli, 
Jour. Cut. Dis., 1904, xxii, p. 573 (histology). 

- Cf. Heller, loc cit., with reference to previously published cases of this type; and 
Whitfield, Brit. Jour. Derm., 1906, xviii, p. 2lM. 

1 Brit. Jour. Derm., 1<)<)(), xii, p. 206. 

1 Vierteljahr, L886, p. 571. 

6 Arehiv, 1902, lx, p. 179 (with histological report and bibliography). 



342 



HYPEREMIAS AND INFLAMMATIONS 



distinguishable or so fused as to render their identification difficult. 
Most English dermatologists 1 believe the annular lesion is formed by 
the fusing of individual papules rising in a ringed arrangement. 
Cavafy 2 asserted that in addition to this form of development certain 
annular lesions were formed by the peripheral extension, with central 
involution, of a single papule. Engman 8 confirmed Cavafy's view by 
proving, both clinically and histologically, that annular lesions are 
developed by both of the methods above outlined. 4 

Fio. 76 




Lichen ruber moniliformis. 



Lichen Planus Erythematosus. — Under this title Crocker describes 
two cases in which the papules were of a deep crimson tint, soft to the 
touch, and obliterated temporarily by pressure. There was in both a 
marked telangiectasis of the face. Crocker mentions a similar case 
reported by Stirling. 



1 Brit. Jour. Derm., 1900, xii, p. 421. 

3 Jour. Cut. Dis.. 1901, xix, pp. 209-222. 

4 Cf. Sutton, Jour. Amer. Med. Assoc, 1914, lxii, p. 175. 



2 Loc. cit. 



LICHEN PL i v/'n 



• i ■ 



Lichen Planus of the Mucous Surfaces (tongue, inner surfaces of the 
checks, lips, epiglottis, glans penis, progenital region of both 
anus, and perianal region) may occur with or without cutaneous symp- 
toms. In some cases of well-marked cutaneous disease the mucous 
membranes arc so slightly affected and attract so little attention thai 
they are overlooked. Dubreuilh 1 believes that more cases of involve- 
ment of mucous membranes occur without cutaneous lesions than of 
the last-named without mucous symptoms. Confusion has been bred 
in these cases by the hastily formed conclusion that the lesions here 
discussed are mucous patches or symptoms of leukokeratosis buccalis. 

Pinhead- to hemp-seed-sized, grouped or isolated, slightly project- 
ing, velvety, smooth, grayish, whitish, rounded lesions may be recog- 
nized as lesions of lichen planus of the mucous surfaces, the color and 

Fig. 77 




Lichen planus of the mucous surface of the tongue. 

si/e varying somewhat with the individual, the age of the disorder, and 
the locality involved. Sometimes a slight halo surrounds the base of 
each; at times they are firm, at others soft to the touch. Again, they 
may send short ramifying striae to the neighboring mucous surface. 
Vomer, 2 and others describe umbilication of the lesions. As distin- 
guished from purely cutaneous lesions, they may be smeared with a 
whitish mucus. 

Lichen Planus Sclerosus et Atrophicus (Hallopeau) and Lichen Planus 
Morphaeicus (Crocker), a rare form of the disease, has been described 



1 Histologic, Lichen plan des Muqueuses, Annales, L906, s. iv, vii. pp. 12:-! r_><>. 
» Zeitschrift, L906, \iii, p. 107; abst. Annates, 1907, s. iv, viii, p. 145. 



344 HYPEREMIAS AND INFLAMMATIONS 

in addition by Morrant Baker and Stowers in England, and by the 
author, 1 Schamberg and Hirschler, 2 and Sutton in this country. 
The characteristic- lesion found in this variety is an irregular, often 
polygonal, flat-topped, white papule. The white color of the lesions 
is striking, and has been compared with that of ivory and mother-of- 
pearl. The papules, as a rule, are firm to the touch, neither elevated 
nor depressed, but slight elevation may be present. Generally, no 
areola is present, but at times a rosy or moderately pigmented /one 
may surround the papules. These may be discrete or grouped, and 
in most cases presenl both types. When grouped to form plaques, 
the outline of the individual papules forming the plaques can be deter- 
mined. Each papule has on its shining, smooth surface from one to 
several black or dark, horny, comedo-like plugs, or minute bead-like 
depressions, which show the former >ite> of horny plugs. These ele- 
ments are situated at the pilosebaceous or sweat-pore orifices, and are 
important from the view-point of diagnosis. 




Lichen planus atrophicus. 

Etiology. — The causes of lichen planus are obscure. It is often diffi- 
cult to recognize the sources of the disease, but in many cases a history 
of nervous exhaustion can be obtained. Grief, long-continued anxiety, 
and overwork, especially when accompanied by great mental strain, 
frequently precede this disorder. Acute and aggravated cases have 
presented themselves before us in several instances following a great 
shock. On the contrary, manv patients are well-nourished and not 
lacking in flesh. In fact, the combination of a fair degree of nutrition 
of the body with nervous exhaustion is to be frequently recognized in 
patients affected with lichen planus. 

D. W. Montgomery and Alderson 3 suggest that the disorder is due 

1 Jour. Amer. Med. Assoc, September 10, 1910, p. 901 (report of 6 cases, with a 
review of the literature). 

2 Ibid., 1909, p. 369. 3 Ibid., October 30, 1909, p. 1457. 



LICHEN PLA \ 346 

to a toxemia. Fordyce comes to the same conclusion in regard to his 
fatal case. Engman and Monk- suggest that lichen planus may be due 
to some constitutional disturbances caused by an infectious microbic 
s it. Numerous observers have reported the occurrence of two or 
more members of a family affected with the disease, several examples 
having come under our own observation. 

Other causes cited are: traumatism dog bite, Walters . digestive 
disturbances, malaria, malnutrition, and diseases of the generative 

2 ms. Within a year we have seen a patient whose attack of lichen 
planus followed the bite of a black ant. The lesions began shortly 
after the bite, which occurred upon the thigh, and -pread in a band- 
like arrangement for some week>. after which they developed pretty 
generally over the body. 

Lichen planus is more common after the second decade of life, and 
is rare in children. Different opinions are entertained respecting the 
frequency with which men and women are attacked. General experi- 
ence points to the conclusions formulated by Crocker, who report- 
more cases among women English than among men, while the 
statistics of the Vienna school reverse the figures. The disease is 
encountered more frequently in private practice, among the nervously 
taxed of the well-to-do cla>-e-. than among out-patients of public 
charities, who suffer to a greater extent than others from cachexia and 
malnutrition. Hoffmann 3 reports the coexistence of lichen planus with 
diabetes. We have made a similar observation. 

The fact that lesions develop along scratch-lines in predi-posed 
individuals leads Jacquet to >tate that lichen planus is always trau- 
matic, and found in individuals with a diminished vasomotor tonus, 
resulting from some disturbance of the nervous centres. Hallopeau 
and Jomier. 4 on the other hand, bring forward as evidence of the para- 
sitic origin of the disease a case in which lichen planus developed along 
scratch-marks in an individual who never had had the disease. A 
similar case was reported by West, 5 in which the scratch-marks were 
produced by a cat. 

Pathology. — The genesis of the disease is not fully explained . Many 
observers believe that lichen planus is a constitutional disease with 
cutaneous manifestations, produced by an unknown toxic agent 
acting on the nerve-centres. Robinson 6 fir>t clearly showed the 
pathological distinction between lichen ruber and lichen planus. His 
observations have been confirmed by those of Boeck, Kaposi, Touton, 
Weyl, and other-. Among reporter- on the histopathology of the dis- 
ease may be mentioned ("rocker. Torok, 7 Joseph, 8 Pinkus, 9 Fordyo 
Engman, 11 Sabouraud, 12 and other-. 

I . cit. 5 Interstate M, I. Jour., June. 1909. 

Innalea, L906, s. iv, vii. p. 420. ; Ibid., 1903, s. iv. iv. p. >2 

Brit. Jour. Derm., 1897, i x . p. p;_>. • Jour. Cut. Dia., 1889, vii, pp. 41, 81. 

it. Mai. Cut.. 1889, i, p. 162 with bibliogra] 

1 Lrchiv, 1 -''7. wwiii. p. 3. 
I id., 1902, 1\. p. L63 3 plat.- and referencee to literal 
lour. Cut. I)i.-., L910, xwiii. p. .">7. I. ■. <-it. 

■* Annates, October, 1910, p. 191; abatr. Brit. .lour. Derm., 1911, nriii, p. 164. 



346 HYPEREMIAS AND INFLAMMATIONS 

The histopathology of lichen planus is characteristic and shows 
unusual uniformity in all types, notwithstanding the wide variation 
in clinical appearances. In all cases there is found a well-defined 
cellular infiltration in the upper part of the corium, consisting chiefly 
of connective-tissue cells and lymphocytes, associated with edema. 
In the epidermis hypertrophy is noted, as evidenced by acanthosis, 
hyperkeratosis, with associated edema, and occasionally a few migrated 
leukocytes. In detail, there is dilatation of the vessels and lymph- 
spaces of the papillary and snbpapillary region, with edema, and a 
sharply outlined cellular infiltration, consisting chiefly of connective- 
tissue cells and lymphocytes. Occasionally, plasma-, mast-, and 
multinuclear-cells and polymorphonuclear leukocytes are sparingly 
found. ( riant-cells are rarely described. The dense* cellular mass may 
at times he so closely associated with the epidermis as to interfere 
with the continuity of the basal layer. The epidermis shows edema, 
and marked hypertrophy of the rete (acanthosis), of the granular 
layer, and of the stratum corneinn (hyperkeratosis). Colloid degener- 
ation occurs in certain of the epithelial cells. A plausible explanation 
of t he process of umbilication i> made by ( 'rocker and Fordyce, to the 
effect that the thickened, horny layer sinks into the rete in a funnel- 
shaped manner, and when eliminated leaves the depression or umbili- 
cation. 

In the hypertrophic form the above described process is exaggerated, 
the epidermal changes being more marked, and the cellular infil- 
tration extending more deeply into the corium, where, in addition, 
increase in the collagenous tissue and newly-formed vessels are 
found. 

The histology of the lesions of the atrophic form, as studied by the 
author, 1 agrees with the original of Darier and others since, and con- 
sists in the main of a sclerosis of the papillary and snbpapillary layers 
of the corium, and a deeply situated cellular infiltration, with, in addi- 
tion, the horny pities extending into the sweat-ducts. In the annular 
variety Engman describes the usual lichen planus picture in the active 
periphery of the ring, occurring, however, in a mild degree. Nearer 
the centre regressive changes are noted, while in the centre a regener- 
ative process is in progress. 

The histology of the mucous-membrane lesions corresponds closely 
to that of the cutaneous lesions. 

Joseph 2 , Whitfield, and others have reported the formation of small 
vesicle-like cavities in the basal layer. Joseph explains the umbilica- 
tion of the papule by absorption of these pseudo-vesicles. 

Diagnosis. — The diagnosis rests upon the characteristic features 
heretofore described. Thus, in its size, apex, color, and course the 
papule of papular eczema is quite different from that described above, 
being brighter, redder, more acuminate at the apex, and much more 
often followed or accompanied by catarrhal symptoms in the skin. In 

1 Loc. cit. 2 Loc. cit. 



LICHEN PLANUS : '>^ 

psoriasis punctata the scales are abundant and readily removed; and 
the individual lesions are increased rapidly by peripheral extension, 
Far beyond the fullest development of the papule of lichen planus. The 
papular syphiloderm is not, as a rule, pruritic, not flattened when 
minute, not polygonal in shape, and not covered with a closely 
adherent, horny scale; and it always occurs in patients in whom care- 
ful investigation discloses other symptoms of the disease (mucous 
patches, adenopathy, etc.). The history and course of the disease 
will determine the diagnosis. 

( nronic lesions of lichen planus on the legs (obtuse, verrucous, hyper- 
trophic) have been confused with the condition of the same parts 
developed in Kaposi's multiple idiopathic pigmented sarcoma. In the 
disorder last named, the elephantiasic aspect of the limb, the infiltra- 
tion of the integument, especially at the root of the toes, and the char- 
acteristic roundish nodules springing from the general surface, suffice 
to render the diagnosis facile. 

The distinctions noted above in connection with lichenification of 
patches of chronic inflammation of the skin are not to be disregarded. 

Treatment. — Systemic treatment depends upon the condition of the 
patient. As many of the subjects of lichen planus are neurotic, neu- 
rasthenic, or suffering from other depressing or debilitating conditions, 
it follows that in many instances it is necessary carefully to regulate the 
diet, habits of rest, sleep, and exercise, and to administer tonics, cod- 
liver oil, and other remedies which will build up the general health. 
In some instances a change of climate, scene, and occupation is of the 
greatest value. 

Arsenic, though sometimes causing an aggravation of the symptoms 
in acute cases, is a valuable remedy in many subacute or chronic and 
extensive cases of the disease. It may be given as directed for the 
treatment of psoriasis. Mercury, in the form of biniodid, bichlorid, 
or the protiodid, is increasingly recognized as of unquestioned value 
in many cases. The protiodid, grain J (0.01), with or without 
arsenous acid, grain t,, (0.0033), may be given three times a day. 
Excellent results have been obtained by us with the hypodermatic 
use of the bichlorid of mercury. Deep injections into the muscle 
are given in the same manner as in syphilis. The dosage varies 
from i to \ of a grain (0.00S to 0.016) every second day. Usually 
a do/en injections are sufficient to relieve an ordinary case. Crocker 
recommends the use of salicin in L5-grain (1.0) doses three times a 
day, and large doses of quinin in an effervescent mixture. Tilbury 
Fox and Robinson found the alkaline diuretics, taken well diluted 
after meals, of value, especially in the generalized hyperemic cases. 
For very acute cases, we have found the remedy of value at times in 
relieving excessive itching. Aspirin in 5-grain (0.33) doses may be 
used for the same purpose. Ilartzell 1 advocates the employment of 

1 Jour. A in. i . Med. Assoc, July 20, 1007, p. 225. 



348 HYPEREMIAS AND INFLAMMATIONS 

the salicylates. Pernet 1 reported a ease of acute lichen planus rapidly 
cured by removal of 7 J c.c. of spinal fluid by a spinal puncture. He 
further reports Ravaut and Thibierge, 2 of Paris, as having worked 

along the same lines in treatment. 

Local treatment should be directed toward the protection of the 
skin and the relief of itching. For many eases the use of a paste and 
dusting-powder, as described in the treatment of eczema and psoriasis, 
gives satisfactory results. A paste containing equal parts of lanolin, 
vaselin, zinc-oxid, and talcum, with from 1 to '.\ per cent, of salicylic 
acid, is usually effective. In very acute and extensive cases, more 
relief sometimes is obtained by the use of the soothing lotions and dust- 
ing-powders recommended for the treatment of the acute stages of 
eczema. The same care should he taken as in eczema to have the 
clothing next the skin of soft cotton or linen. In many instances 
bathing once a day in tepid oatmeal- or bran-water, with or without 
the addition of an alkali, may precede the application of the paste or 
other remedy. Some patients, especially those with much scaling 
and infiltration of the -kin, are made more comfortable with the use 
of ointments than with pastes. In subacute and chronic cases tar, in 
the form of lotion, ointment, or paste, is often of value. Directions 
for its use are given in the section on Eczema. For stubborn patches 
the treatment differs little from that recommended for inveterate 
psoriasis. For hypertrophic areas, salicylic acid is most effective. It 
may be applied in a paste or ointment containing from 30 to 60 grains 
2. I. to the ounce (30.) ; or, better, it may be dissolved in equal parts 
of alcohol and ether, and the solution painted on the patch. The alco- 
hol and ether evaporate and Leave the acid in contact with the lesion. 
After a sufficient amount has been applied, the whole may be covered 
with adhesive plaster. The dressing should be changed every day or 
two, and when the part becomes greatly inflamed a soothing dressing 
should be substituted. Brocq and Jacquet recommend the daily use 
of a tepid douche for from two to ten minutes at a time, alternated with 
the application for a few seconds of a cold spray. 

For chronic cases with much infiltration, the .r-rays are indicated. 
We have used the method, in conjunction with other treatment, in a 
large number of eases with decided improvement, including relief of 
itching in all, and unusually rapid recovery. The number of exposures 
in each case varied from two to nine, and the technique was that com- 
monly employed for psoriasis. 

Prognosis. — The prognosis is in general favorable, since even cases 
of long standing are relieved when the subjects of the disease are 
placed under conditions favorable for recovery. When the patient 
is neurasthenic, the eruptive symptoms may persist for years, accom- 
panied by intense itching and a consequent teasing of the nervous 
centres. In this class of subjects it is generally well to make a guarded 
prognosis, and to pronounce upon the future with reserve. 

1 Brit. Jour. Derm., 1913, xxv, p. 261. 2 Annals, 1913, p. 4G1. 



LICHENIFICATION '.',1'.) 



LICHENIFICATION. 1 

Synonyms. Lichen Simplex Chronica (Vidal). Fr., Nlvrodermite. 

Definition. This term was applied by Brocq to denote a condition 
in the skin where the normal lines are increased and the skin becomes 
thickened, producing patches resembling lichen planus. 

Symptoms. — The disorder may be local, or more or less diffuse. Early 
there is intermittent itching in the area, which induces rubbing and 
scratching, this being followed by various changes in the skin. It be- 
comes darker in color and thickened, the normal lines being increased, 
producing Hat, irregular papules, some of which have a faceted appear- 
ance. The surface of a fully formed patch is divided into more or less 
elevated, triangular, square, or irregular areas, presenting a mosaic-like 
appearance. Moderate scaling occurs. The patches vary in shape, 
being oval, irregular, or angular in outline. They occur most frequently 
over the nape of the neck, the upper and internal surfaces of the thighs, 
the loins, the anterior and external part of the leg, the scrotum, the 
vulva, the popliteal and axillary folds, and on the palms and soles. 
They may be single or multiple, and they present a tendency to sym- 
metrical distribution. The itching is intense, the paroxysms being 
worse at night. 

In the generalized cases the skin becomes discolored and pigmented, 
and interspersed here and there are patches similar to those described 
above, with papules irregularly distributed over the surface. A group 
of cases described by Fox, 2 Fordyce, 3 and Haase, 4 presenting a lichenoid 
eruption in the axillary and pubic regions, closely resembles the group 
of cases above described. In these cases the eruption is described as 
being composed of numerous small, firm, smooth, and rounded papules, 
which are aggregated, and form deeply infiltrated patches, slightly 
reddened or of the normal hue of the skin. Intense itching leads to 
scratching, wdiich produces secondary changes. 

The disorder occurs in neurotic individuals, and in those who have 
undergone nervous strain. Many of the etiological factors mentioned 
in connection with lichen planus apply to this disorder. The disease 
is persistent, and when relieved tends to recur, the axillary cases having 
been particularly resistant to treatment. A variety of lichenification 
may follow certain inflammatory conditions of the skin, such as eczema. 

Histopathology. — The principal changes consist in hyperkeratosis, 
acanthosis, cellular infiltration, and edema in the papillary layer of 
the corium, without much change in the blood-vessels. In the axil- 
lary cases described by Fordyce and Ilaase, similar changes were 

1 For full discussion of the subject, sec Brocq's chapter on " Les Lichens," La Pratique 
I )erm., Tome iii, p. l L9. 

-■lour. Cut. Dis., 11)02, xx, p. 1: Two cases of a fare papular disease affecting the 

axillarj regions (histopathologic report by Fordyce). 

8 Trans. Amer. Derm. Assoc., 1908, p. 1 IS : A chronic, itching, papular eruption 
of the axilla and puhes: its relation to neurodermatitis. 

'Jour. Amer. Med. Assoc., January 21, 1911: A chronic, itching, papular eruption 
of the axilla*, puhes, and breast. 



350 HYPEREMIAS AND INFLAMMATIONS 

noted, with the additional involvement of the sweat-coils. These 
were dilated; some of the tubules contained partial or complete casts, 
and their (-(41s had undergone parenchymatous degeneration. An 
infiltration of lymphocytes and plasma-cells occurred about the blood- 
vessels and in the region of the coils. In otiier places the collagenous 
tissue had undergone mucoid degeneration. 

Diagnosis. — The disorder is to he differentiated from lichen planus 
and papular eczema. In the former condition the patches have a 
better definition; their color i- more marked, being of a violaceous or 
reddish tint; the flat-topped, shining papules are more definite; white 
stria" over the papules are likely to he present; and the sites of pre- 
dilection, over the flexors of the wrists and about the ankles, are 
different. 

Treatment. The treatment i-> similar to that employed in chronic 
eczema, and consists in stimulating applications containing tar, salicylic 
acid or resorcin. For localized patches, we have found radiotherapy 
the most successful method of treatment. The general management 
is that indicated by the individual case. 

LICHEN NITIDUS. 

This disorder was fir>t described in 1907 by Pinkus. 1 A clinical and 
histological Study of the disease has since been made by kyrle and 
McDonagh, 2 Arndt, 8 Sutton, 4 and Reines. 6 

Symptoms. The disorder resembles lichen planus to a moderate 
degree. The lesions are small, glistening papules or nodules, sharply 
defined, roughly circular or polygonal in outline, slightly raised above 
the level of the surrounding skin, and pinkish in color or of the same 
line as the surrounding skin. They occur in groups, without coalescence 
<>l' the individual papules. In the centre of a papule or nodule a fine 
aperture has been described. No particular arrangement of the lesions 
occurs. The favorite sites have been the genital region, the abdomen, 
breast, flexors of the elbows, and palms of the hands. As a rule, the 
lesions remain localized, but a more general distribution has been noted. 
Subjective sensations are absent, and it is suggested that the disease 
has so long remained undeseribed for this reason. The disorder is 
chronic. 

Etiology. — The disorder has occurred, in most cases, in men, only 
one case having been reported in a woman. Tuberculosis is suggested 
as the etiological factor, from the histological architecture. However, 
animal experiments have thus far been negative. In the case described 
by Kyrle and McDonagh, a positive reaction was obtained after the 
injection of tuberculin. 

1 Ueber eine neue knotchenformige Hauteruption: Lichen nitidus. Archiv, Ixxxv, 
p. 11. 

2 Brit. Jour. Derm., 1909, xxi, p. 339. 

3 Zeitsehrift, xvi, p. 551; abstr. Brit. Jour. Derm., 1910, xxii, p. 30. 

4 Jour. Cut. Dis., 1910, xxviii, p. 597. 

5 Med. Klin., 1910, xxx; abstr. Brit. Jour. Derm., 1911, xxiii, p. 299. 



TMPETIOO 351 

Pathology. The pathogenesis of the disease is unknown. The 
histopathology ii|>i><-;t¥-^-^ to be characteristic, the disease belonging to 
the granulomata. The cellular infiltration is situated chiefly in the 
papillary and subpapillary layers of the curium. 'Flic infiltration is 
dense and well defined, and consists of giant-cells, epithelioid, and 
mononuclear round cells. The collagen in the affected area shows 
degenerative changes, and in certain cases has practically entirely dis- 
appeared in the infiltrated areas. The epithelial changes are secondary. 
Directly over the nodule, the epidermis is thinned, but on either side 
prolongation of the epithelial pegs is noted. No tubercle bacilli or 
caseous degeneration has been found, and animal experiments have 
been negative. 

Diagnosis. — The disease is to be distinguished chiefly from flat 
warts and lichen planus. From the former it may be distinguished 
by the small size of the lesions, their greater number, and their dis- 
tribution; from the latter by the absence of itching, absence of color, 
the distribution of the lesions, and their arrangement. 

Treatment. — Sutton reports the disappearance of lesions in his case 
with the use of a salicylic-acid and resorcin ointment, used alternately 
with a benzoinated zinc-oxid ointment. 

IMPETIGO. 

Synonyms. — Ger., Eiterflechte. Fr., Impetigo, Dartre humide. 

The various forms of impetigo described by older writers are now 
otherwise classified, leaving impetigo contagiosa, impetigo of Bockhart, 
and impetigo herpetiformis as the only diseases designated by this 
title. There is little connection between these three, except that they 
arc pustular dermatoses. The impetigo of Bockhart is a superficial 
pustular folliculitis, and impetigo herpetiformis is a rare and grave 
disorder. 

Impetigo Contagiosa (Tilbury Fox). — Impetigo contagiosa is a con- 
tagious disease of the skin, characterized by vesicles, pustules, and 
superficial crusts, usually occurring on exposed portions (the face and 
hands), devoid of subjective sensations, and terminating without 
sequels. 

Symptoms. — The early lesion is a flat and erythematous spot or a 
vesicle, the latter rapidly changing into a pustule, which subsequently 
dries, forming a superficial crust. In most cases the lesions are located 
on the face, ears, neck, and hands, but any part of the cutaneous sur- 
face may be attacked, including the mucous membrane. 

The crusts are gummy-like, yellowish, or occasionally darker colored 
when admixed with blood. They are very superficial and appear to 
be stuck on the skin. They extend somewhat beyond the borders of 
the original lesion, and their edges are sometimes slightly curled up- 
ward. Underneath the crusts there is a superficial erosion, having a 
distinct outline. When the crust is removed, there is presented simply 
a reddened, weeping surface. The lesions vary from pinhead- to 



352 



HYPEREMIAS AND INFLAMMATIONS 



dime-sized or larger; rarely there is a sprinkling of red papules asso- 
ciated. In a given ease all the lesions above described are usually 
present. In children, pustular lesions of the fingers are not uncom- 
monly associated with impetigo of the face. Stomatitis is observed 
from time to time. .Montgomery 1 reports a group of cases of involve- 
ment of the lips, month, throat, nostrils, eyelids, and conjunctiva. 

Fig. 79 




Impetigo contagiosa, superficial type. 



Impetigo Contagiosa Gyrata. — This is a clinical variety of the dis- 
ease in which the lesions spread peripherally, clearing in the centre, 
forming circles, and by coalescence with other lesions produce a gyrate 
appearance. Schamberg 2 reported a remarkable instance of this type. 
Crocker, 3 in 1895, described this variety as having been seen in 
England only during the past two years. While this form is un- 
common, it is met with sufficiently often to be easily recognized. 



1 Jour. Cut. Dis., 1910, xxviii, p. 445. 
3 Brit. Med. Jour., November 2, 1895. 



2 Ibid., 1896, xiv, p. 169. 




Impetigo contagiosa. 
Fig. 81 




23 



Circinatc impetigo. (MacKee.) 



354 HYPEREMIAS AND INFLAMMATIONS 

Impetigo Contagiosa Bullosa. This is a descriptive term for that 
variety of the disease in which bullous formation predominates. It is 
uncommon in adults except in warm countries. Sir Patrick Manson 1 
has described this form under the title: "Pemphigus Contagiosus 
Occurring in Children as well as Adults." Corlett 2 reported a very 
interesting epidemic of this type occurring in soldiers recently returned 
from Florida, after the close of the Spanish-American war. In several 
carefully observed cases Corlett described the evolution of the lesions 
in the main as follow-: 

The lesions begin with one or more small, reddish spots, from pin- 
head to split-pea in size. After about twelve hours, the epidermis 
becomes slightly raised with a clear, serous fluid. The vesicle thus 
formed extend- peripherally, commonly attaining a size varying from 
I to o c.c. in diameter. The epidermic covering of the bulla is thin, 
and rubbing of the clothing i- sufficient to cause its rupture, leaving a 
shrivelled tent, containing a serous fluid in its folds. About the third 
day the content- of unruptured vesicles become opaline or tinged with 
streaks of yellow, the latter process beginning below and extending 
upward. The entire contents rarely become purulent. The bleb rises 
from the sound skin, in most instances, without an areola or other 
sign of inflammation. At first fully distended, after maturity it be- 
comes flaccid; at other times the blebs are round, oval, or horseshoe- 
shaped. In all instances there is marked tendency to extend periph- 
erally, and after rupture the distal margin is the only part distended 
with fluid. At times the centre heals, while the serous undermining 
of the epidermis continues at the periphery, giving rise to the regular 
ring or gyrate lesions. When the epidermis is removed, there appears 
a moist area, at fir-t reddish and glazed, which later becomes covered 
with a light coating of friable crusts or tissue-paper-like scales. After 
healing, slight pigmentation remains for a month or so. 

The location of lesions of this type is the face, the hands, the axillae, 
and, finally, a generalized distribution. 

In older children and adults, a bullous impetigo may follow vaccina- 
tion, 3 or may occur independently, this form having been seen by the 
author, particularly in public practice, the bullae very closely simu- 
lating those seen ordinarily in pemphigus. Pmgman 4 states that bullous 
impetigo is not uncommon in St. Louis, particularly in the summer. 
Iu infants the disease occurs sporadically and epidemically. It is 
comparatively common, 5 and is known as Pemphigus Neonatorum. It 
frequently occurs in epidemics in obstetric wards of public institutions, 
and in foundling homes, and many cases have been traced to the practice 
of certain midwives. 

1 Manson on Tropical Diseases, 1898. 

2 Cleveland Jour, of Med., 1898, iii. p. 513. 

3 Elliot, Jour. Cut. Dis., 1894, xii, p. 194. 

4 Ibid., 1901, xix, p. 180 (with extensive bacteriological bibliography). 

5 Foerster, Jour. Amer Med. Assoc, 1909, liii, p. 358 (with discussion of the relation- 
ship between impetigo contagiosa and pemphigus neonatorum, and literature) ; Biddle, 
Jour. Cut. Dis., 1914, xxxii, p. 268 (a report of two epidemics of so-called pemphigus 
neonatorum). 



IMPETIGO 355 

The lesions develop at variable periods after birth, beginning on any 
part of the body and spreading to other portions. They consist of 
vesicles and bulla', usually situated on an erythematous base and occur- 
ring in various sizes, with serous or purulent contents. The lesions 
often hurst before reaching maturity, the area meantime spreading 
over a space with a diameter of several centimeters. After bursting, 
the areas of involvement spread, with centrifugal denudation of the 
epidermis. The fluid furnished by the lesions is scanty or abundant, 
of a yellow or (especially in cases that have proved fatal) grayish tinge. 
In mild cases the lesions are few and constitutional symptoms absent. 
In others there is a rapid development of the lesions over large sur- 
faces, with an early fatal termination. Rarely there are constitutional 
symptoms, including- inappetence, elevation of temperature, diarrhea, 
and exhaustion. 

The several clinical pictures of impetigo differ on account of the 
greater or lesser diffusion of the contagious elements in each case; also, 
the vulnerability of the skin, largely expressed by the age of the patient, 
and also by climatic conditions, the serious extensive and bullous form 
occurring in warm or hot climates. In the ordinary case there may only 
be a few isolated, pea-sized or larger vesico-pustules on one hand; or 
many may be scattered about the mouth and lips; or dense, greenish 
crusts may succeed such lesions over the occiput or scalp; or there 
may be much larger pustulo-bullous lesions over the legs, which are 
torn, scratched, and thickly covered with pustular or hemorrhagic 
incrustations. 

Etiology. — The disease is a pus infection, the result of the trans- 
mission to the skin, through the medium of the finger-nail, filthy or 
otherwise, of an infection of streptococci, staphylococci, or both. In 
children the disease is often associated with pyogenic nasal infection. 
It may be conveyed from one child to another, and hence is frequently 
contracted in schools. Women contract the disease from children, 
while in men the most frequent source of infection is the barber-shop. 
The eruption often occurs during convalescence from a more or less 
actively contagious disease. The antecedence of some fever in many 
( -ases is admitted by all observers. Duhring and Fox have seen it 
follow vaccinia. It may occur typically in a series of children, each of 
whom is convalescent from varicella. 

Montgomery and Morrow 1 reported a large increase in impetigo 
following the great San Francisco fire, and suggested that the spread 
was due to flies, opportunity for infection being presented by the dis- 
organized state of society at that time. In the infantile and epidemic 
cases infection is simply transmitted either directly or by mediate 
objects. Even with strict precautions the disease will spread in an 
obstetrical ward when once started, and the epidemics following in the 
wake of midwives indicate the factor there. 

A large number of observers have examined the lesions bacteriologic- 

1 .lour. Cut. Dis., 1909, xxvii, p. 135. 



356 HYPEREMIAS AND INFLAMMATIONS 

ally, and in the major number of cases staphylococci have been found. 
Griffon and Balzer, 1 Sabouraud, 2 Leroux, 3 Gilchrist, 4 and many others 
have found streptococci in unruptured vesicles. Engman 6 obtained 
the Staphylococcus pyogenes aureus in pure culture in 7 out of 8 cases; 
and in the infant variety Foerster 8 also obtained chiefly the Staphylo- 
coccus pyogenes minus. Clegg and Wherry 7 isolated a diplococcus in 
5 cases studied in the Civil Hospital at Manila. This organism was 
identical with the Micrococcus pemphigi neonatorum. 6 Dohi and Dohi 9 
describe two forms found in Japan one produced by a white staphy- 
lococcus, the other by a streptococcus. Both forms may be infected 
ondarily by a yellow staphylococcus. 

From a survey of all the findings, it is apparent that both staphy- 
lococci and streptococci arc concerned etiologically in the production 

of the disease. 

Pathology.- The cause of the disease being an infectious one, a patho- 
logical study has been made (largely of the vesicles, bullae and crusts) 

to determine chiclK whether a particular organism could be implicated. 
The histology of an early lesion is well described by Gilchrist. n The con- 
tents of the vesicle consisted of a large number of polynuclear leuko- 
c\ to-, a considerable number of round mononuclear cells, a few detached 
epithelial cells, a small quantity of fibrin, and a large quantity of coag- 
ulated albumin (serum). There was a collection of polynuclear cells 
in the vesicle; and in the collection were found, on special staining, 
a large aumber of cocci, which, on culture from other vesicles, proved 
to be the Staphylococcus pyogenes aureus. 

The vesicle was situated between the horny and mucous layers. 
The stratum mucosum was swollen, and numerous polynuclear leuko- 
cyte- were found traversing this layer. The corium, chiefly in the 
upper part, showed an acute inflammatory condition, indicated by 
dilated vessels, serous infiltration, increase in the number of round and 
mononuclear cells, and numbers of migrated polynuclear leukocytes. 
In cultures taken at this time Gilchrist only succeeded in obtaining 
the Staphylococcus aureus and albus. In his later work, as above 
mentioned, he was able to obtain a streptococcus. 

Unna 11 states that the cocci are never found in leukocytes, and that 
they are always extracellular. Engman, 12 on the contrary, found both 
large masses and small numbers of cocci within the bodies of leuko- 
cytes; from which fact the latter draws the conclusion that the virulence 
of the organism is mild. 

Dewevre 13 reports a number of successful inoculations and autoinocu- 
lations practised with the contents of the vesico-pustule, w 7 ith finely 

1 La Presse med., 1897, lix, p. 130. 

2 La Pratique Derm., 1901, ii, p. 878. 3 Annates, 1893, iv, p. 290. 
4 Trans. Amer. Derm. Assoc., 1899, p. 87. 5 Loc. cit. 

6 Loc. cit. 7 Jour. Infect. Dis., 1906, p. 165. 

8 Almquist, Ztschr. f. Hyg., 1891, p. 253. 

9 Archiv, 1912, cxi, p. 629; abstr. Jour. Cut. Dis., 1913, xxxi, p. 123. 

10 Duhring's Cutaneous Medicine, vol. ii, p. 431. 

11 Histopathology, p. 189. 12 Loc. cit. 
13 Arch, de Med. et de Pharm. mil., 1885, vi, p. 210. 



IMPETIGO dot 

powdered impetiginous crusts, and with the products of scraping the 
subjacent erosion. In 1884, Dr. Hyde reproduced an almosl typical 
vesico-pustule upon the left forearm by inoculation with the moistened 

debris of crusts. This inoculation was done in the clinic, the crusts 
being taken from typical lesions upon the face of a younggirl inoculated, 
while under observation, from the lesions of exactly similar character 
on the face of her twin sister. The lesion on the forearm produced 
a characteristic crust, which in seven days was also used for the inocu- 
lation of two students then present at the clinic, in one of whom there 
was no result and in the other an abortive lesion. 

Diagnosis. — To establish the identity of this affection, it is necessary 
to define the exact differences between it and eczema pustulosum. 
These differences are: first, the absence of infiltration of the tissues 
affected; second, the absence of itching; third, the failure of the 
lesions to form patches; fourth, the isolation and wide separation of 
lesions distinctly pustular; fifth, the large development and rather per- 
sistent character of the pustules; sixth, the evident termination of the 
disease, which does not, as in many cases of eczema, progress to form 
a freely discharging and crusting surface, the pustular being but the 
initial stage of a distinct morbid process. Manifestly, however, an 
impetigo of the sort described is not incompatible with an eczema 
which is often originated by less irritating causes. 

In ecthyma the pustules are in appearance much more formidable 
than those of impetigo, in consequence of their size, depth, inflam- 
matory base, areola, flat, hard and bulky crust, and erosive action upon 
the skin. 

In varicella the lesions are small, much more widely distributed over 
the body, and are vesicular only, rarely bullous. In pemphigus and 
herpes iris the seat, character, and period of evolution of the lesions 
suffice to establish the diagnosis. 

From hyphogenous sycosis it is so readily distinguished that the 
differential points need not be described. The latter is mentioned 
only for the reason that it represents the disease popularly called 
"barber's itch;" while today large numbers of barber-shop cases of 
contagious impetigo are erroneously being called, both by physicians 
and laymen, "barber's itch." 

Treatment. — Pustules, when present, are to be opened with an aseptic 
needle, the purulent contents gently removed by irrigation with a mild 
antiseptic solution, such as boric acid, and the lesion dressed with a 
mild antiseptic ointment, such as a 1 to 4 per cent, ointment of ammoni- 
ated mercury. In the ordinary cases in children, this procedure will 
readily clear up the trouble. In adults, in the common types about 
the face and hands, the procedure may be as follows: Bathe the areas 
thoroughly in the eveningwith a 1 to 2000 bichlorid solution. Afterthe 
bath apply an anunoniated mercury ointment in the strength of 3 to ~) 
percent. In the morning repeal the bichlorid bath, after which apply 
a dusting-powder composed of the mild chlorid of mercury 1 drachm 
(4.), boric acid 1 drachm (4.), and talcum powder 6 drachms (24. . 



358 HYPEREMIAS AND INFLAMMATIONS 

In the epidemic infant variety, Foerster obtained good results by 
opening the vesicles and bullae and applying a 2 per cent, ammoniated 
mercury ointment. The individual lesions were dressed to prevent 
their spread. In addition, a general hath was given in a warm per- 
manganate of potassium solution. This appeared to he of value also 
in preventing autoinoculation. In extensive cases external heat, with 
strychnin and brandy, was also recommended as a supporting measure. 

Ecthyma (Ger., Ekthyma, Eiterblase). — Ecthyma is a pustular infec- 
tion of the skin of the same nature as impetigo, hut of deeper situation. 
It is inoculahle and autoinoculahle, and characterized chiefly by the 
formation of large, flat, variously colored crusts. 

Symptoms. The disease occurs most frequently on the lower extremi- 
ties, chiefly below the knees; in children about the buttocks. The 
inflammatory process is comparatively deep-seated. 

The primary lesion is a vesicle or a vcsico-pustule, situated on an 
inflamed base, the inflammatory process soon extending deeply. The 
lesion spreads peripherally, and in the course of several more days 
crust-formation occurs. As the crust dries, it becomes dark-brownish 
in color and firmly attached at the margins. Beneath the crust a 
superficial ulcerative process proceeds, the margin of this area being 
elevated, producing a crater-like appearance when the crust is removed. 
The elevation of the margin causes the shallow ulcer to appear deep, 
in the course of from two to four weeks, healing occurs beneath the 
crust, the latter being exfoliated, leaving usually a slight scar, with 
more or less pigmentation. 

In certain debilitated states, a gangrenous ulcer appears in place of 
the one described, which is more deeply situated, causes greater de- 
struction of ti>>ue, and is followed by more intense sequels. 

The subjective phenomena are sensations of heat, burning, pain, and 
soreness. In certain cases there may be accompanying lymphangitis 
or adenopathy. In public practice a mixture of symptoms may be 
present, due to trauma and to autoinfection from scratching. 

Etiology. — Among predisposing factors should be mentioned a loss 
of resistance through ill health. The infection, therefore, occasionally 
follows anemia, asthenia, and the convalescence from many diseases. 
It is a disease usually seen in the cachectic and poorly nourished of the 
public-patient class and rarely in private practice. Improper and 
insufficient food, bad hygiene, over-work, and uncleanliness are all 
predisposing factors. The exciting cause is the same as that of im- 
petigo, and investigators disagree as to whether it is the streptococcus 
or the staphylococcus. A larger number of microorganisms have been 
isolated here than in impetigo. The identity of cause between these 
two disorders is frequently seen by their presence in an individual at 
the same time, typical lesions of impetigo being present on the face, 
with those of ecthyma on the limbs below the knees. In CorlettV 
cases occurring in soldiers this fact was well illustrated. 

1 Loc. cit. 



IMPETIGO 359 

Balzer and Griffon, 1 in a study of ;i number of cases of ecthyma, 
found in all cases streptococci in the form of diplococci-like fine grains. 
When cultivated, tins organism presented the features of Streptococcus 
pyogenes, and experimentally it was pathogenic. 

Pathology. The pustule of the disease differs from the pustule of 
eczema or the pustule of impetigo in the severer exudative process b\ 
which it is produced, and in its limitation to the exact site of external 
irritation. Early there is found in the corinm the usual evidences of 
inflammation — dilated blood-vessels, with perivascular cell-infiltration, 
and migration of leukocytes up into the epidermis. In severe cases, 
necrosis occurs, destroying the papillary layer, the result being a 
cicatrix, which contracts as it grows older, and which in mild cases is 
finally barely visible as a minute, cicatriform punctum. According 
to Unna, the ecthyma pustule, as distinguished from that of impetigo, 
is less an epidermal abscess than the result of epidermal inflammation, 
fibrinous at the centre and exceedingly edematous at the periphery. 
The crust contains fibrin and epidermal layers. 

Sabouraud points out that the original streptococcic infection is 
often succeeded by a secondary microbian involvement, whereby the 
staphylococci present are enabled to produce the peripheral lesions of 
impetigo and furunculosis. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction between 
them is largely artificial and based upon the severity of the inflam- 
matory process, there is small danger in consequence. Kaposi ex- 
presses the truth in his suggestion that there can be but little objection 
to the employment of the term "ecthyma' 1 when it is desired to char- 
acterize precisely the pustular grade of any cutaneous inflammation at 
a given time. The pustules of variola are "ecthymaform," and many 
of those seen in syphilis exhibit similar characters; but the history of 
the general affection should throw light upon the identity of the cuta- 
neous disease. In syphilis, moreover, the ulceration at the base of 
the lesion exhibits the pronounced features of the syphilitic ulcer in 
its secretion, floor, edges, base, crust, and career, The crust, in par- 
ticular, of the flat, pustular syphiloderm has the rupioid, conical appear- 
ance which suggests the shell of the oyster, and the underlying ulcer 
is larger and deeper than in ecthyma. In the furuncle there is usually 
a ('(Mitral core. In impetigo the pustules are not deep-seated, and there 
is no ulceration at the base; the crust is superficial, yellowish, firmly 
adherent, and the lesions are more numerous. 

Treatment. The general treatment of patients affected with ecthyma 
is a matter of importance. A proper regulation of the food and hy- 
gienic surroundings is not to be neglected. Tonics arc frequently 
indispensable, including iron, quinin, and strychnin. 'The destruc- 
tion of any pedicull and the cleansing of the skin with soap and water 
will often be sufficient to effect a great change. This fact is well illus- 

1 Loc. cit. 



360 HYPEREMIAS AND INFLAMMATIONS 

trated in hospital practice, where young patients rapidly improve after 
a bath, followed by inunction with vaselin, and a few substantial meals 
of a nutritious character. When the lesions are abundant, the treat- 
ment is in general that of pustular eczema. Ousts are to be removed 
after soaking with oil or fat; and the floors of the former pustules, 
after washing with carbolated water, should be dressed with an oint- 
ment containing from 10 to 15 grains (0.66-1.) of ammoniated 
mercury to the ounce (30.) of lard. If the minute basal ulcers are 
sluggish, they may, after careful cleansing, be touched with a small 
swab that has been dipped in a 5 per cent, formalin solution or in a 
solution of mercuric chlorid in tincture of benzoin, 1 grain (().()()()) to 
the ounce ( :!().). Phenol or boric acid or iodoform may be employed 
for the same purpose. For the salve mentioned above may be sub- 
stituted one containing 10 grains (0.66) of calomel, or ] drachm (2.) of 
bismuth subnitrate to the ounce (30.) of salve-base. 

Veldt Sore (Natal Sore) (Barkoo; Iuim><> Rot of Queensland), — 
Under this title has been described a disorder which ( 'rocker 1 reported 
as somewhat common among the medical officers and soldiers of the 
English army during the late war in South Africa. It most often 
attacked cavalrymen. As distinguished from the Natal sore, which 
was chiefly found in the lower part of that country, the veldt sore 
was most abundant in the high, barren table-lands. Multiple lesions 
appeared on the hands, forearms (chiefly on the backs), feet, and legs, 
but were rare on the face and other portions of the body. A pinhead- 
sized, itching papule, vesicle, or pustule first appeared, subsequently 
enlarging and filling with a yellowish scrum, which later became turbid, 
ruptured, and left a small- to large-coin-sized, painful, crusted ulcer, 
exuding sero-pus, and often accompanied by inflammation of the lym- 
phatics and glands. In some eases the back of the hand was entirely 
covered. 

The disease is produced by pyogenic microorganisms. Castellani 
and ( nalmers 2 found streptococci in the lesions. The Staphylococcus 
aureus has been isolated (Harland). Crocker was inclined to believe 
that the disorder is a semitropical varient of impetigo contagiosa. 

Treatment. — The usual treatment of such infected lesions (boric-acid 
fomentations and ointments) was speedily effectual. 

DERMATITIS VEGETANS. 

Under the title of Pyodermite vegetante, Hallopeau 3 describes five 
cases of a disease affecting chiefly the scalp, axillae, genitals, groins, 
lips, and the mucous membrane of the mouth, in which there appear 
miliary pustules, which soon are surrounded by a hyperemic base. 
The pustules appear in successive groups, coalesce, and the area thus 
formed becomes covered with crusts, beneath wdiich form more or less 

1 Dis. of the Skin, 3d ed., 1903. p. 1075. 

2 Manual of Tropical Med., p. 1468. 

3 Archiv, 1898, xliii, p. 289; and xlv, p. 323. 



ii RUNCULU8 361 

elevated vegetating surfaces. These patches may increase by periph- 
eral extension, l>ut more commonly by the formation of new pus- 
tules at the border. On the mucous membranes, rupture of the pustules 
is followed frequently by superficial ulcers. The disease yields readily 
to antiseptic treatment, leaving only a pigmentation, which gradually 
disappears. Hallopeau considered the disorder a type of local infec- 
tion spreading by autoinoculation. Similar cases have been reported 
under the title of Dermatitis ret/dans by Ilartzell, 1 Jamieson,- Crocker/ 5 
King-Smith, 4 Pernet, 6 Pusey, 6 Fordyce and Gottheil, 7 and others. 
Wende and DeGroat 8 report 6 cases in infants, with 4 collated 
from the literature. Six of the 10 developed during the course of 
eczema, 4 independently of any other dermatosis. In these the 
lesions began as papulo-pustules, followed by crusts and vegetations. 
The face and seal]) were chiefly involved, but in some the wrists, arms, 
and legs were involved. In all there was the same type of papulo- 
pustules appearing in groups; the resolution of old lesions with the 
appearance of new; the production of vegetations; and the disappear- 
ance of the disease under antiseptic treatment. The disorder is prob- 
ably the result of an infection, and not directly related to the eczema 
which preceded the disease in some of the cases. 

The disease is distinguished easily from pemphigus vegetans, which 
it resembles clinically, by the readiness with which it yields to anti- 
septic treatment, and by its failure to affect the general health of the 
patient. 

FURUNCULUS. 

Synonyms. — Furuncle, Boil. Fr., Furoncle, Clou; Ger., Furunkel, 
Blutgeschwur, Eiterbeule, Eitergeschwur. 

Definition. — A furuncle is a staphylococcic infection of a hair- 
follicle, producing a painful cellulitis, which terminates in the death of 
tissue and the expulsion of a necrotic plug. Furunculosis is the suc- 
cession of furuncles. 

Symptoms. — Furuncles commonly begin as tender and painful indu- 
rations in the skin or its subjacent tissues, the summit of each 
nodule soon becoming visible in the epidermis as a reddish punctum. 
A furuncle is the result of an active inflammatory process, limited to a 
definite area, and of greatest intensity at the centre of the involved 
mass. This centre is often represented by a hair-follicle, the pustule 
that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface or fairly im- 
bedded within or beneath the derma. A yellowish point in the centre 

1 Jour. Cut, Dis., 1001. \ix, p. 465 (with histology). 

2 Brit, Jour. Derm., 1902, xiv, p. 107. > [bid., 1909, xxi. p. 87. 

1 .l«.ur. Cut. Dis., L910, xxviii, p. 605. • [bid., 1912, x\\. p. 517. 

1 [bid., liHHi. xxiv. p. 555. [bid., 1906, mv, p. 543. 

.« Ibid., 191 1. \\ix, i'. 17.;. 



362 HYPEREMIAS AND INFLAMMATIONS 

of the erythematous swelling soon announces the occurrence of sup- 
puration. When accidentally or artificially opened at this summit, 
exit is given to thick, yellowish pus, with which blood may be commin- 
gled from the traumatism of neighboring capillaries. The small abscess 
may then, after discharging its purulent contents for a tew days, gradu- 
ally close by granulation; or may also expel from its cavity a tenacious, 
pus-covered, yellowish-green slough, known as the "core." This 
evacuation is usually followed by relief of the tense and throbbing pain 
which is the well-known subjective characteristic of the furuncle. 

The length of time requisite for the completion of this process 
varies, with the extent of tissue involved, from a few days to several 
weeks. Boils may occur in any part of the body, but are most common 
about the face, the auricular region, the neck, the armpits, the ano- 
genital surfaces, the hips, the buttocks, the breast, and the extremities. 
They may occur as single or as multiple lesions, or they may succeed 
each other in crop-, especially about the buttocks, trunk, and thighs, 
for a period of several months. The disease of the skin may produce 
;i constitutional effect, manifested in pyrexia, which is usually encoun- 
tered only iii individuals of irritable constitution, when the furuncles 
are few and short-lived. There i^ also a decided chloroanemia, due to 
pain, fever, purulent drain, irritability of nervous centres, inappetence, 
and consequent perversion of nutrition. 

The sequels of boils are maculations of a violaceous tint, often per- 
ceptible in the skin for week- and even months after disappearance 
of the lesions; and pinhead- to penny-sized cicatrices, which are per- 
manent. 

Etiology. --The exciting cause of furunculus is local infection with 
one of the pyogenic microorganisms, usually, if not always, the Staphy- 
lococcus pyogenes aureus, 1 though other pus-producing cocci also are 
found in the lesions. The remote cause is often exceedingly obscure. 
It is true that boils are encountered in typical subjects of diabetes, of 
the exanthemata, and of "hospitalism," in whom anemia, asthenia, 
marasmus, malnutrition, and exhaustion resulting from excesses, from 
grave general disease, from low fevers, and from nervous strain, play a 
prominent part. But the reverse is also true. 

Scratching, eczema, scabies, other cutaneous diseases, lice, and 
external irritants of various sorts are responsible for many boils, espe- 
cially those that are few and not followed by similar lesions. When, 
however, such sequence occurs, it should not be forgotten that the 
pus is autoinoculable, and that furuncles, if sufficiently numerous and 
large, are capable of disturbing the general economy. A collar-button 
at the back of the neck; the edges of an unyielding corset in one unaccus- 
tomed to it; a hard bench; a saddle-tree; a velvet coat-collar shelter- 
ing the germs responsible for a previous attack; and many similar 
articles may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 

1 Gilchrist, Johns Hopkins Hosp. Reports, 1903, xiv. 



FURUNCVLUS 363 

of externally operating poisons. In this category musl be Included 
arsenical wall-papers, and the poisons handled in the trades, e. g., by 
dyers, lead-manufacturers, and others. 

Lastly, it is exceedingly common for patients thus affected to apply 

to practitioners for remedies intended to "purify the blood;' 5 and, 
inasmuch as potassium iodid is often prescribed in response to this 
demand, the original trouble is thus enhanced to a manifold extent. 
Many cases of furimculosis are instances of boils, resulting originally 
from external irritation, that have greatly multiplied and finally pro- 
foundly affected the system under the impulse of the so-called "blood- 
purifying" process. 

Pathology. — According to Unna, most furuncles begin with an 
impetiginous lesion due to the inoculation of the pilo-sebaceous fol- 
licle with pus-coeei, the organism being, in the majority if not in all 
instances, the Staphylococcus pyogenes aureus. The eoeei penetrate 
deeply into the follicle, into ramifications of the sebaceous gland, and 
into the surrounding tissue. An abscess surrounding the follicle is thus 
produced, which undergoes a necrosis en masse, producing the char- 
acteristic central core or slough. It is probable that in some instances 
the cocci are carried along the lymph-vessels to form abscesses about 
the neighboring follicles and glands. The lanugo hair-follicles are 
affected much more frequently than those of the stronger hairs. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
aggravated symptoms of the latter. Circumscribed furuncular ab- 
scesses of the groins and the axilhie are not to be confounded with sup- 
purating, sympathetic, or virulent buboes of these regions, associated 
with genital or extragenital contagious venereal sores. Errors of this 
sort have been made. Furuncles of the anal and genital regions in 
point of diagnosis may be significant of surgical affections of the neigh- 
boring parts (perineal, periprostatic, periurethral, and scrotal abscesses 
in men; suppuration of the vulvo-vaginal gland in women). 

Treatment. — The debilitated constitution of many patients affected 
with boils indicates clearly the need of a tonic regimen, including the 
administration of iron, quinin and strychnin, the mineral acids, and 
a generous diet of milk, cream, eggs, and fresh meats. To these articles 
of diet, wines and malt liquors may at times be added with advantage. 
Change of climate, of diet, of cooks, and of habits of life is most ser- 
viceable in cases of prolonged furimculosis. The mineral w T aters at 
some health-resorts prove especially valuable for the debility which 
often results from these disorders. The urine should always be exam- 
ined for sugar, albumin, and an excess of urates. The internal remedies 
which possess reputation in this complaint are arsenic, sulphur, the 
alkalies, tar, fresh yeast in tablespoonful doses, phosphorus, and the 
syrup of the hypophosphites of calcium, iron, sodium, and potassium. 
Calcium sulphid, which was once more highly esteemed than any 
other of the internal remedies named, is given in doses of ,',, to .-, grain 
(0.0066 0.0133) every three or four hours. It is doubtful whether the 
drug exerts any influence whatever upon furuncles. In lithemia 



364 HYPEREMIAS AND INFLAMMATIONS 

potassium acetate or citrate is given in large dilution, or the liquor 
potassae; in gout colchicunij salol, and the alkalies, including sodium 
salicylate. No one of these articles, however, may be described as an 
efficient and certain remedy for the complaint ; many cases will progress 
without hindrance from any or all of them. Fresh brewer's yeast, 
recommended by Lowenberg, Crocker, Brocq, 1 Desfosses, 2 and others, 
i^ sometimes of service. A tablespoonful or less may be given three 
times a day. 

Attempts in the direction of aborting a furuncle by the topical appli- 
cation of the stronger alkalies (aqua ammonise) or acids, caustics, 
cautery, ice, iodin, or phenol, or premature complete excision with 
the scalpel, occasionally succeed, but often they fail. Boils maybe 
aborted at times by the injection beneath the lesions of from 3 to () 
drops of a •! per cent, solution of phenol. 

The objects of local treatment are to reduce the inflammatory 
process, allow the free escape of pus, and prevent infection of other 
follicles in the neighborhood. The surface of the boil and the skin in 
the neighborhood should be kept thoroughly clean by frequent use of 
hot water and green soap, and tin* application at least twice daily of 
some simple antiseptic solution, such as .">() per cent, alcohol, 1 per cent. 
phenol lotion, or weak bichlorid solution. Stelwagon 3 recommends 
for the purpose: 

I{ Resorcin., 
Acidi borici, 
AJcoholis, 
Aquae dest., f3v; 150 M. 

Before rupture of the furuncle it may be protected by means of an 
ointment or paste containing ichthyol, 1 to 2 drachms (4.-8.) to the 
ounce (30.); or, by protecting the surrounding skin with such an oint- 
ment or paste, hot antiseptic applications may be applied to the lesion 
itself. A convenient and effective dressing at this stage is found in the 
official cataplasma kaolini, containing sterilized clay, glycerin, and a 
mild antiseptic. Such a dressing mav be continued even after the 
opening of the furuncle, if care be taken to permit free discharge of 
the pus. 

Jackson 4 recommends boring into the boil, as soon as it has pointed, 
with a stick sharpened to a fine point, covered with cotton, and 
saturated with 95 per cent, phenol. The surface and surrounding 
parts are then cleansed with hydrogen peroxid, or a 1 to 1000 solution 
of bichlorid of mercury; after which a 5 to 10 per cent, salicylic-acid 
ointment is applied. 

The furuncle should be opened freely with a clean incision when 
pus has formed, but not before. Violent squeezing of the furuncle to 
separate its slough or evacuate the contents should never be prac- 

1 La Presse med., 1899, lxi, p. 45 (with bibliography). 

2 Ibid., 1892, liv, p. 653. 3 Diseases of the Skin, 7th Ed., p. 411. 
4 Amer. Jour. Med. Sci., June, 1909. 



ur. w-xxx; 


1-2 


5jss; 


6 


f5i; 


30 


fgv; 


150 



C [RBUNCULUS 365 

Used, though it is permissible in some instances to scrape oul the 
contents with a curette. The cavity should be cleansed thoroughly, 

at least twice a day, with hydrogen peroxid, or with a solution of 
phenol or mercuric chloral, and packed with boric-acid, aristol, or 
other powder. Iii place of these powders, phenol in crystal or in 
strong solution may be employed. 

In the chronic recurring lesions about the back of the neck, a 
moderate course of radiotherapy is a valuable method of treatment. 
Vaccine therapy is valuable in a certain proportion of cases, especially 
the chronic forms. Autogenous vaccines are preferred, though stock 
vaccines are often of much value (for technique, see section on General 
Therapeutics). 

Prognosis. — Eventually, the worst cases are relieved, when unaccom- 
panied by systemic or visceral disorders, and when the circumstances 
of the sufferer permit him to pursue the most advantageous course 
(travel, diet, and rest). The resulting cicatrices depend upon the 
severity of the process. Often they are small and in the course of 
years become scarcely distinguishable; in exceptional cases they are 
large, persistent, and disfiguring. Lympius 1 calls attention to the 
serious and even fatal complications (purulent arthritis, meningitis, 
thrombosis of frontal veins, septic infarct in lung) which may com- 
plicate furunculosis of the face, particularly of the upper lip, owing to 
the vascularity of the region. 

CARBUNCULUS. 

Synonyms. — Anthrax Simplex, Carbuncle. Ger., Karbunkel, Brand- 
schwar; Fr., Anthrax. 

Definition. — A carbuncle is an acute, flattish, circumscribed, cuta- 
neous and subcutaneous abscess, usually larger than a furuncle, that 
is due to the presence of staphylococci, and is characterized by dense 
induration and sloughing, terminating, in favorable cases, by the pro- 
duction of a persistent cicatrix. 

Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the site 
of the lesion. In cases in which the carbuncle is formidable and seated 
upon or near the head, alarming symptoms of prostration, stupor, 
somnolence, and even coma, may be noted. With and without these 
concomitants, a dense, dull-red, indurated, and painful phlegmon soon 
appears, varying in size from that of a small hen's egg to that of an 
orange and even much larger, involving not only the skin, but also the 
tissues beneath. Suppuration finally occurs, but the pus is not con- 
fined to a single space; it undermines the integument aial often through 
several apertures leaks out indolently to the free surface. The fene- 
strated or cribriform appearance of the skin covering the carbuncle 
constitutes in this stage 1 one 1 of its most striking features. Through 

1 Deut. med. Wehnschrft., 1899, utv, p. 17 I. 



366 HYPEREMIAS AND INFLAMMATIONS 

these apertures may be distinguished the whitish or yellowish pus- 
soaked sloughs or portions of a single slough, which can at times he 
extraeted through the orifice. Often the entire mass separa